Your activity: 58 p.v.
your limit has been reached. plz Donate us to allow your ip full access, Email: sshnevis@outlook.com

What's new in anesthesiology

What's new in anesthesiology
Authors:
Marianna Crowley, MD
Nancy A Nussmeier, MD, FAHA
Literature review current through: Feb 2022. | This topic last updated: Feb 28, 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

Dental problems associated with oral dissolving buprenorphine (January 2022)

There are >300 reports of dental problems associated with use of buprenorphine formulations dissolved in the mouth, including the buccal formulation and sublingual tablets [1,2]. Reported problems include dental caries, abscesses, and damaged teeth, many of which have required tooth removal. The incidence of dental problems with buprenorphine is unknown. Patients who use orally dissolving buprenorphine should swish and swallow water after the drug has dissolved, see a dentist soon after starting the drug, and make sure the dentist knows they are taking the drug. The US Food and Drug Administration (FDA) has issued a related safety advisory and will mandate a label change. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Buprenorphine for chronic pain'.)

Perioperative gabapentinoids do not reduce risk for prolonged opioid use (November 2021)

Gabapentinoids have been included in perioperative opioid-free and opioid-sparing anesthetic protocols, but outcome data have been discordant and an increase in adverse events (eg, sedation, dizziness, visual disturbances) has been observed. Furthermore, in a retrospective study including nearly 14,000 patients ≥65 years of age undergoing a broad range of surgical procedures, preoperative gabapentinoid administration was not associated with a reduced risk of opioid use in the 90 days after surgery [3]. To limit postoperative chronic opioid use, our approach is to use the lowest dose of opioid for the shortest period of time while providing adequate analgesia. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Opioid-free and opioid-sparing anesthetic techniques'.)

Consensus on guiding principles for perioperative pain management (October 2021)

Evidence-based multidisciplinary guidelines for the management of acute perioperative pain have been lacking. Recently, a consortium of various specialty organizations published consensus recommendations for seven guiding principles for perioperative pain management (table 1) [4]. We agree with these principles, which seek to improve perioperative pain management by implementing multimodal, opioid-sparing, patient-centered approaches. (See "Management of acute perioperative pain", section on 'General approach'.)

AIRWAY MANAGEMENT

Updated difficult airway guidelines for adults and children (December 2021)

The American Society of Anesthesiologists has updated its difficult airway guidelines for both adult and pediatric patients and created new algorithms (algorithm 1 and algorithm 2) and infographics. The new guidelines stress prioritizing oxygenation throughout airway management; confirming ventilation with end tidal CO2 regardless of the airway device used; and limiting attempts with each device or technique to three, with one more attempt by a more experienced operator [5]. The new guidelines also provide robust guidance for extubation. (See "Management of the difficult airway for general anesthesia in adults", section on 'Importance of an algorithmic approach'.)

CARDIOVASCULAR AND THORACIC ANESTHESIA

Use of TEE for perioperative management of ECMO (October 2021)

Echocardiography is a valuable diagnostic and monitoring tool often used before and during extracorporeal membrane oxygenation (ECMO) support, but few guidelines are available to help cardiac anesthesiologists who are frequently facilitating ECMO insertion and management. Now, the Society of Cardiovascular Anesthesiologists has published two consensus statements that include guidance regarding the role of transesophageal echocardiography (TEE) in performing patient assessments before initiating ECMO, facilitating insertion and final positioning of ECMO cannulae, monitoring and troubleshooting during ECMO support, and managing the weaning process [6,7]. We employ TEE guidance during perioperative management of ECMO. (See "The role of TEE in the management of extracorporeal membrane oxygenation", section on 'Uses of echocardiography for extracorporeal membrane oxygenation'.)

NEUROANESTHESIA

General anesthesia versus monitored anesthesia for deep brain stimulator placement (October 2021)

Whether deep brain stimulator (DBS) placement with the patient asleep versus awake affects outcomes has been uncertain. In a randomized trial comparing general anesthesia (GA) versus monitored anesthesia care (MAC) in 110 patients with Parkinson's disease undergoing frame-based microelectrode-guided DBS, both groups had similar motor function improvement and frequency of adverse effects [8]. Although MAC with patient feedback has been preferred because it allows precise microelectrode placement and intraoperative stimulation testing, GA may be a reasonable alternative for patients who may not tolerate MAC. (See "Anesthesia for deep brain stimulator implantation", section on 'Choice of anesthetic technique'.)

OBSTETRIC ANESTHESIA

Neuraxial anesthesia and delivery in individuals with VWD (November 2021)

In a retrospective review of 106 deliveries among 71 individuals with von Willebrand disease (VWD) seen by a high-risk anesthesia consult service, neuroaxial anesthesia was used in 89 percent without complications [9]. Treatment with desmopressin (DDAVP) or a von Willebrand factor (VWF) concentrate was used in approximately one-third. Postpartum hemorrhage occurred in approximately 10 percent, mostly following cesarean delivery. We believe that most individuals with type I and mild-to-moderate type II VWD may receive neuraxial anesthesia, especially with good antepartum planning and as long as their VWF levels can be maintained at 50 to 100 international units (IU)/dL. VWF levels decline rapidly following delivery, and close monitoring is needed postpartum. (See "von Willebrand disease (VWD): Treatment of minor bleeding and routine care", section on 'Delivery and postpartum care'.)

PREOPERATIVE AND POSTOPERATIVE MANAGEMENT

Benefits of patient blood management (December 2021)

Patient blood management (PBM) programs provide guidelines for appropriate use of blood transfusion. In a new series involving >400,000 hospital admissions over an eight-year period, institution of a PBM program was associated with a 22 percent reduction in transfusions [10]. Hospital length of stay and adverse events were also reduced, and there was an estimated cost savings of USD $7 million. PBM programs should not supersede clinical judgment in transfusion decisions, but when well designed and thoughtfully implemented, they can improve quality of care and reduce risks, costs, and burdens associated with transfusion. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Hospital-wide oversight programs/patient blood management'.)

IV placement, venipuncture, and blood pressure measurements after breast cancer surgery (October 2021)

Avoiding lymph node dissection is the only preventive measure proven to reduce the risk of developing lymphedema after breast cancer surgery; however, many patients are told to avoid intravenous catheters, venipunctures, and blood pressure measurements in the arm ipsilateral to the previous surgery for the rest of their lives. In agreement with the American Society of Breast Surgeons, the Society for Ambulatory Anesthesia issued a statement that these measures are not contraindicated in patients who have no lymphedema, even if they have had an axillary lymph node dissection [11]. Our approach is generally consistent with this statement. We support shared decision-making that accounts for the individual's risk factors for developing lymphedema, the clinical situation and monitoring needs, and patient preferences. (See "Breast cancer-associated lymphedema", section on 'Unsupported risk reduction strategies'.)

REGIONAL ANESTHESIA

Spinal versus general anesthesia for hip fracture surgery (December 2021)

Whether the use of spinal versus general anesthesia for hip fracture surgery affects outcomes is uncertain. In a multicenter randomized trial (REGAIN) comparing the two techniques in 1600 patients who underwent hip fracture surgery, both groups had similar mortality, ability to walk at 60 days postoperatively, postoperative delirium, and time to discharge [12]. The spinal anesthesia group had lower rates of in-hospital mortality, acute kidney injury, and critical care admission, but statistical analysis was not performed for these outcomes. For patients in whom either type of anesthesia would be appropriate, we suggest spinal anesthesia to reduce the need for mechanical ventilation and achieve a more rapid return to baseline mental status. (See "Anesthesia for orthopedic trauma", section on 'Choice of anesthetic technique for hip fracture'.)

OTHER ANESTHESIA

Timing of elective surgery after COVID-19 (January 2022)

The appropriate time to schedule elective surgery after COVID-19 is unclear. In a multicenter database study of >5000 patients in the United States with COVID-19 who underwent major elective surgery, surgery in the first four weeks after COVID-19 diagnosis was associated with higher risks of postoperative pneumonia, respiratory failure, sepsis, and pulmonary embolism [13]. These findings are consistent with a prior international study that found increased 30-day mortality after surgery performed within seven weeks of COVID-19 diagnosis. Risks were higher in patients with symptomatic COVID-19 and highest in those symptomatic at the time of surgery. The decision to schedule elective surgery should consider the severity of COVID-19, the risks of complications, and the risks of delaying surgery. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Risk related to timing after infection'.)

Effect of neuraxial versus general anesthesia on postoperative delirium (January 2022)

Compared with general anesthesia, neuraxial or regional anesthesia with light, deep, or no sedation does not consistently decrease the incidence of delirium or other perioperative neurocognitive disorders (PND). A randomized trial in older patients undergoing hip fracture surgery noted a similar incidence of delirium in those who received neuraxial anesthesia (spinal and/or epidural) without any sedation compared with those who received general anesthesia [14]. Similar results have been noted in other randomized trials. We select an appropriate anesthetic technique based on considerations other than risk for PND. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Choice of anesthetic technique'.)

Clinical indications for perioperative point-of-care ultrasound (November 2021)

Point-of-care ultrasound (POCUS) in the perioperative setting includes airway, lung, and gastric ultrasound; focused cardiac ultrasound; focused assessment for trauma examination; and guidance during regional, vascular, and pain management procedures. Clinical benefits of POCUS have been noted for selected elective diagnostic uses or performance of procedures, and for urgent determination of causes of perioperative hemodynamic instability. We agree with expert panel recommendations on use of POCUS by anesthesiologists and pain physicians for these indications when equipment and expertise are available [15]. (See "Overview of perioperative uses of ultrasound", section on 'Clinical indications'.)

Avoiding delay in indicated cataract surgery (November 2021)

Although many patients with cataracts are older adults with comorbidities, few conditions preclude proceeding with indicated cataract surgery for those who can tolerate the required positioning because no blood loss or fluid shifts occur. Moreover, significant delays (ie, more than four months) for cataract surgery have been associated with increased morbidity due to greater likelihood of falls, automobile accidents, and worsening cognitive impairment. We agree with the new Society for Ambulatory Anesthesia position statement that recommends against postponing cataract surgery unless the patient has an acute condition that requires time to achieve optimal medical management [16]. (See "Anesthesia for elective eye surgery", section on 'Anesthetic considerations'.)

REFERENCES

  1. Suzuki J, Mittal L, Woo SB. Sublingual buprenorphine and dental problems: a case series. Prim Care Companion CNS Disord 2013; 15.
  2. https://www.fda.gov/media/155352/download.
  3. Young JC, Dasgupta N, Chidgey BA, et al. Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records. Anesth Analg 2021; 133:1119.
  4. Mariano ER, Dickerson DM, Szokol JW, et al. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2022; 47:118.
  5. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31.
  6. Mazzeffi MA, Rao VK, Dodd-O J, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459.
  7. Mazzeffi MA, Rao VK, Dodd-O J, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478.
  8. Holewijn RA, Verbaan D, van den Munckhof PM, et al. General Anesthesia vs Local Anesthesia in Microelectrode Recording-Guided Deep-Brain Stimulation for Parkinson Disease: The GALAXY Randomized Clinical Trial. JAMA Neurol 2021; 78:1212.
  9. Reale SC, Farber MK, Lumbreras-Marquez MI, et al. Anesthetic Management of Von Willebrand Disease in Pregnancy: A Retrospective Analysis of a Large Case Series. Anesth Analg 2021; 133:1244.
  10. Warner MA, Schulte PJ, Hanson AC, et al. Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center. Mayo Clin Proc 2021; 96:2980.
  11. Society for Ambulatory Anesthesia (SAMBA) Statement on Intravenous Catheter Placement, Venipuncture and Blood Pressure Measurements in the Ipsilateral Upper Extremity after Breast Cancer Surgery with and without Axillary Lymph Node Dissection https://samba.memberclicks.net/assets/docs/SAMBA_Statements/SAMBA_Statement_IV-Breast-Surg.pdf (Accessed on October 19, 2021).
  12. Neuman MD, Feng R, Carson JL, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med 2021; 385:2025.
  13. Deng JZ, Chan JS, Potter AL, et al. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States. Ann Surg 2022; 275:242.
  14. Li T, Li J, Yuan L, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA 2022; 327:50.
  15. Haskins SC, Bronshteyn Y, Perlas A, et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications. Reg Anesth Pain Med 2021; 46:1031.
  16. Sweitzer B, Rajan N, Schell D, et al. Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2021; 133:1431.
Topic 112615 Version 10977.0

References

1 : Sublingual buprenorphine and dental problems: a case series.

2 : Sublingual buprenorphine and dental problems: a case series.

3 : Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records.

4 : A multisociety organizational consensus process to define guiding principles for acute perioperative pain management.

5 : 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

6 : Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation.

7 : Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting.

8 : General Anesthesia vs Local Anesthesia in Microelectrode Recording-Guided Deep-Brain Stimulation for Parkinson Disease: The GALAXY Randomized Clinical Trial.

9 : Anesthetic Management of Von Willebrand Disease in Pregnancy: A Retrospective Analysis of a Large Case Series.

10 : Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center.

11 : Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center.

12 : Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

13 : The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States.

14 : Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial.

15 : American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications.

16 : Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement.