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What's new in anesthesiology

What's new in anesthesiology
Authors:
Marianna Crowley, MD
Nancy A Nussmeier, MD, FAHA
Literature review current through: Nov 2022. | This topic last updated: Dec 30, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ACUTE AND CHRONIC PAIN

CDC updates opioid prescribing guidelines (November 2022)

The United States Centers for Disease Control and Prevention (CDC) has published a new guideline for prescribing opioids for acute, subacute, and chronic pain, updating their 2016 guideline (table 1). The guideline is intended for clinicians who prescribe opioids to outpatients ≥18 years of age and does not apply to pain related to sickle cell disease, cancer, palliative care, or end of life care [1]. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid therapy in the context of the opioid epidemic'.)

Combination pharmacotherapy for painful diabetic neuropathy (August 2022)

Combination pharmacotherapy is frequently used for patients with painful diabetic neuropathy that does not respond to initial monotherapy, despite limited data to support the efficacy of this practice. In a multicenter trial of 130 patients with painful diabetic neuropathy who were given initial monotherapy with amitriptyline, pregabalin, or duloxetine, those whose pain did not improve at six weeks were given a second agent from a different pharmacologic class [2]. At 16-week follow-up, combination strategies consisting of pregabalin added to amitriptyline, amitriptyline added to pregabalin, or pregabalin added to duloxetine all provided greater benefit than monotherapy, and each strategy provided similar (approximately 50 percent) pain reduction relative to baseline pain. These results support the strategy of combination pharmacotherapy for patients with painful diabetic neuropathy that does not respond to initial monotherapy. (See "Management of diabetic neuropathy", section on 'Inadequate response to initial therapy'.)

AIRWAY MANAGEMENT

Routine preintubation fluid bolus does not prevent cardiovascular collapse in critically ill adults (June 2022)

Hypotension occurs in up to 50 percent of critically ill patients during and after intubation, and can cause cardiac arrest. If time permits, preintubation hemodynamic optimization is recommended, including correction of hypovolemia. However, in a randomized multicenter trial in >1000 critically ill adults, routine administration of a 500 mL intravenous (IV) fluid bolus prior to intubation did not reduce the incidence of cardiovascular collapse compared with no fluid bolus [3], consistent with a previous smaller trial. Methods to reduce peri-intubation hypotension should be individualized and may include use of etomidate or ketamine for induction, use of vasopressors, and IV fluid if necessary. (See "Complications of airway management in adults", section on 'Hemodynamic changes'.)

CARDIOVASCULAR AND THORACIC ANESTHESIA

Prothrombin complex concentrate versus plasma for coagulopathy and bleeding after cardiopulmonary bypass (September 2022)

Unactivated prothrombin complex concentrate (PCC) is used to rapidly correct warfarin anticoagulation. Observational studies have described off-label use of PCC to treat surgical coagulopathic bleeding, but supporting data are limited. One randomized trial compared administration of PCC 15 International Units/kg with fresh frozen plasma (FFP) 10 to 15 mL/kg in 100 patients who had excessive microvascular bleeding with prothrombin time (PT) >16.6 seconds and international normalized ratio (INR) >1.6 after cardiac surgery with cardiopulmonary bypass [4]. Overall efficacy and safety were comparable between PCC and FFP, and patients receiving PCC had improved correction of PT and INR. Before considering administration of PCC or FFP, we treat other causes of intractable bleeding (eg, surgical sources, thrombocytopenia, low fibrinogen levels, platelet dysfunction). (See "Reversing anticoagulation and achieving hemostasis after cardiopulmonary bypass", section on 'Prothrombin complex concentrate (PCC) products'.)

Guidelines for perioperative management of patients with pulmonary hypertension and right heart failure (September 2022)

Pulmonary hypertension with right heart failure is a risk factor for perioperative morbidity and mortality. In a recently published consensus statement, the International Society for Heart and Lung Transplantation recommended a multidisciplinary approach to preoperative assessment to ensure that the indication and benefits of surgery are reasonable and that the patient's condition is optimal for surgery [5]. Intraoperative considerations include use of invasive monitoring for higher-risk cases, use of slowly titrated epidural or spinal neuraxial anesthesia as appropriate, and induction of general anesthesia with etomidate with appropriate use of vasopressors. Vigilant postoperative monitoring is necessary for early recognition and treatment of complications. (See "Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure", section on 'Risks of anesthesia and surgery'.)

PEDIATRIC ANESTHESIA

New guidance for pediatric advanced life support in patients with confirmed or suspected COVID-19 (August 2022)

The American Academy of Pediatrics (AAP) has released specific guidance for advanced life support of children with suspected or confirmed COVID-19 that supplements the previously released 2022 guidance provided by the American Heart Association [6]. Among the key changes from prior guidance, modifications to in-hospital pediatric resuscitation no longer emphasize endotracheal intubation as a priority procedure to reduce aerosol exposure during pediatric cardiopulmonary resuscitation (CPR). Other changes focus on ventilated children who arrest: They should have the advanced airway checked to ensure that it is connected, patent, and in proper position and then remain connected to a closed ventilator system with an inline high efficiency particulate air filter. If they are prone at the time of arrest, they should initially receive compressions with the hand centered over the T7 to T10 vertebral bodies and then be safely turned to the supine position to continue CPR. The AAP guidance also provides initial ventilator settings to use during pediatric CPR. (See "Pediatric advanced life support (PALS)", section on 'COVID-19 patients (suspected or confirmed)'.)

Laryngospasm during pediatric sedation outside of the operating room (August 2022)

Laryngospasm during pediatric procedural sedation is rare but serious, and a better understanding of risk factors may help guide care. In the largest study to date, which included over 275,000 sedations in children performed outside of the operating room, the unadjusted prevalence of laryngospasm was 3.3 per 1,000 cases [7]. On adjusted analysis, risk factors for laryngospasm included concurrent upper respiratory infection (odds ratio [OR] 3.9), airway procedures (OR 3.7), and, compared with propofol alone, use of propofol with ketamine (OR 2.5) or with dexmedetomidine (OR 2.1). Risks associated with ketamine and propofol as single agents were similar. These findings provide a strong rationale for appropriate airway expertise for all providers of pediatric sedation and identify important factors to consider when determining sedation regimens for children. (See "Procedural sedation in children outside of the operating room", section on 'Adverse outcomes'.)

Ultrasound guidance for peripheral intravenous line placement in children (June 2022)

In children, ultrasound guidance is well established for central venous access, but its role for placement of peripheral intravenous (PIV) lines is less clear. A new meta-analysis including five randomized trials performed in children with difficult intravenous access (DIVA) found improved rates of first attempt success (odds ratio 4.6) and overall success (odds ratio 3.3) for ultrasound-guided compared with standard (landmark) techniques during PIV line placement [8]. Based on these data, we suggest using ultrasound-guidance as the initial approach for placing PIV lines in children (but not neonates) with high DIVA scores. (See "Principles of ultrasound-guided venous access", section on 'Children with difficult access'.)

PREOPERATIVE AND POSTOPERATIVE MANAGEMENT

Timing of surgery after ischemic stroke (December 2022)

The risk of perioperative stroke is increased in patients with a prior ischemic stroke, though optimal timing of surgery after stroke is unclear. In a database study including nearly six million patients, the risk of postoperative ischemic stroke was increased eightfold in patients who had a stroke within 30 days before surgery, compared with those who never had a stroke [9]. The risk of recurrent stroke decreased and leveled off for surgery between 60 and 90 days after stroke, but remained elevated. The timing of surgery in patients with prior ischemic stroke should consider the risk of recurrent stroke and the risk of delaying surgery. We suggest delaying elective surgery for at least three months, and if possible up to nine months, after a stroke to reduce the risk of recurrence. (See "Perioperative stroke following noncardiac, noncarotid, and nonneurologic surgery", section on 'Timing of surgery after ischemic stroke'.)

Markers of liver fibrosis and risk of surgical mortality (December 2022)

The benefit of checking preoperative liver biochemistries in healthy individuals is uncertain because most patients with abnormal biochemistries do not have advanced liver disease. However, emerging data suggested that an elevated FIB-4 score, which consists of age, aminotransferases, and platelet count, may be associated with increased surgical mortality. In a large cohort study of individuals without known liver disease, a preoperative FIB-4 score ≥2.67 (defined as the threshold for advanced fibrosis) was associated with increased risk of intraoperative mortality, mortality during hospitalization, and 30-day mortality [10]. While biochemical markers of liver disease may have a future role for assessing surgical risk, additional studies are needed to confirm these findings. (See "Assessing surgical risk in patients with liver disease", section on 'Screening for liver disease before surgery'.)

Preoperative exercise training before lung cancer resection surgery (December 2022)

Some prehabilitation programs include physical exercise training before elective major surgery. In a meta-analysis of 10 randomized trials with over 600 total patients undergoing open or video-assisted resection of non-small cell lung cancer, preoperative aerobic, resistance, and/or respiratory muscle training reduced the risk of postoperative pulmonary complications by over 50 percent and reduced postoperative hospital stay by more than two days [11]. Similar results were noted in previous systematic reviews. Preoperative exercise training likely has benefits in selected patients undergoing lung resection, particularly those with poor functional capacity. (See "Overview of prehabilitation for surgical patients", section on 'Physical exercise programs'.)

Risk factors for mortality after major surgery in older adults (October 2022)

Multiple factors contribute to the increased perioperative risk associated with older age. In a prospective study of nearly 1200 major surgeries among community-living adults ≥65 years old (mean age 79 years), one-year mortality rates were higher in those with frailty (28 versus 6 percent) or probable dementia (33 versus 12 percent), and in those requiring urgent surgery (22 versus 7 percent) [12]. These findings add to other evidence suggesting that absolute age alone has only a modest impact on postoperative outcomes and should not be used as a sole criterion to guide decisions regarding patient selection for a major procedure. (See "Anesthesia for the older adult", section on 'Preanesthesia consultation'.)

Perioperative management of biologic disease-modifying antirheumatic drugs (September 2022)

There is limited evidence to inform the optimal timing of use for biologic disease-modifying antirheumatic drugs (DMARDs) in the perioperative period among patients with systemic rheumatic diseases. In a meta-analysis of cohort studies including over 7300 patients on biologic DMARDs for systemic rheumatic diseases who were undergoing surgery, patients who continued biologics did not appear to be at an increased risk for surgical site infection or delayed wound healing [13]. Stopping biologics prior to surgery, however, was associated with higher rates of disease flares (26 versus 7 percent). These findings are limited by the retrospective and heterogenous nature of the evidence. Our general approach to patients on biologic DMARDs undergoing elective surgery is to withhold the medication at the end of the dosing cycle if disease activity permits. (See "Preoperative evaluation and perioperative management of patients with rheumatic diseases", section on 'Biologic DMARDs'.)

New guidance on COVID-19 testing before elective surgery (July 2022)

During the initial COVID-19 pandemic, many guidelines recommended universal SARS-CoV-2 testing prior to surgery, with a possible delay of elective surgery for patients who test positive. Now, an updated joint statement from the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation suggests that in areas of low-to-moderate community SARS-CoV-2 transmission, institutions may choose to not require preoperative testing for asymptomatic, vaccinated patients scheduled for lower-risk procedures [14]. They continue to recommend universal preoperative testing in areas of high COVID-19 transmission and for symptomatic patients. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Preoperative screening and testing'.)

OTHER ANESTHESIA

Low risk of systemic complications after cataract surgery (November 2022)

In a retrospective cohort study of Medicare beneficiaries, the group undergoing cataract surgery had a lower incidence of systemic complications within seven days of surgery than those undergoing other types of elective low-risk outpatient procedures (7.7 versus 13 to 52 percent) [15]. An anesthesia provider was present for most cataract procedures, but systemic complications remained low in the six percent that had no anesthesia care (7.4 percent in this group). These data underscore the low risk of systemic complications in patients undergoing cataract surgery, even without anesthesia care. (See "Anesthesia for elective eye surgery", section on 'Systemic complications'.)

Blood pressure and oxygen targets following sudden cardiac arrest (September 2022)

Supporting data to guide specific blood pressure and oxygen targets after sudden cardiac arrest (SCA) are limited, and practice is variable. In a recent open-label, two-by-two factorial trial, 789 patients with SCA were randomly assigned to a high versus low mean arterial pressure (MAP) target (77 versus 63 mmHg) as well as a restrictive versus liberal arterial oxygen tension (PaO2) target (68 to 75 versus 98 to 105 mmHg) [16,17]. At 90 days, rates of death or severe disability/coma at discharge were similar across all groups. Although the trial had limitations and confidence intervals were wide, these results do not support aggressive MAP goals or overly restrictive oxygenation in the care of patients after cardiac arrest, pending future studies. (See "Intensive care unit management of the intubated post-cardiac arrest adult patient", section on 'Hemodynamic monitoring and goals'.)

  1. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1.
  2. Tesfaye S, Sloan G, Petrie J, et al. Comparison of amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin for the treatment of diabetic peripheral neuropathic pain (OPTION-DM): a multicentre, double-blind, randomised crossover trial. Lancet 2022; 400:680.
  3. Russell DW, Casey JD, Gibbs KW, et al. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2022; 328:270.
  4. Smith MM, Schroeder DR, Nelson JA, et al. Prothrombin Complex Concentrate vs Plasma for Post-Cardiopulmonary Bypass Coagulopathy and Bleeding: A Randomized Clinical Trial. JAMA Surg 2022; 157:757.
  5. McGlothlin DP, Granton J, Klepetko W, et al. ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery. J Heart Lung Transplant 2022; 41:1135.
  6. Morgan RW, Atkins DL, Hsu A, et al. Guidance for Cardiopulmonary Resuscitation of Children With Suspected or Confirmed COVID-19. Pediatrics 2022; 150.
  7. Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med 2022; 80:485.
  8. Mitchell EO, Jones P, Snelling PJ. Ultrasound for Pediatric Peripheral Intravenous Catheter Insertion: A Systematic Review. Pediatrics 2022; 149.
  9. Glance LG, Benesch CG, Holloway RG, et al. Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery. JAMA Surg 2022; 157:e222236.
  10. Zelber-Sagi S, O'Reilly-Shah VN, Fong C, et al. Liver Fibrosis Marker and Postoperative Mortality in Patients Without Overt Liver Disease. Anesth Analg 2022; 135:957.
  11. Granger C, Cavalheri V. Preoperative exercise training for people with non-small cell lung cancer. Cochrane Database Syst Rev 2022; 9:CD012020.
  12. Gill TM, Vander Wyk B, Leo-Summers L, et al. Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults. JAMA Surg 2022; 157:e225155.
  13. van Duren BH, Wignall A, Goodman S, et al. The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications: Surgical Site Infection, Delayed Wound Healing, and Disease Flares Following Orthopaedic Surgical Procedures. J Bone Joint Surg Am 2022; 104:1116.
  14. ASA and APSF Statement on Perioperative Testing for the COVID-19 Virus. The Anesthesia Patient Safety Foundation. Available at: https://www.apsf.org/news-updates/asa-and-apsf-joint-statement-on-perioperative-testing-for-the-covid-19-virus/ (Accessed on August 03, 2022).
  15. Perumal D, Dudley RA, Gan S, et al. Anesthesia Care for Cataract Surgery in Medicare Beneficiaries. JAMA Intern Med 2022; 182:1171.
  16. Kjaergaard J, Møller JE, Schmidt H, et al. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1456.
  17. Schmidt H, Kjaergaard J, Hassager C, et al. Oxygen Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1467.
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