October 2014

October’s journal picks are brought to you by Judith Dinsmore, Consultant Neuroanaesthetist at St George’s Hospital, London. The first of October’s manuscripts is a special article from this month’s JNSA about perioperative stroke. Perioperative stroke can be a catastrophic complication and is associated with a 8-fold increase in mortality. Neuroanaesthetists are often asked for advice regarding the management of these patients. This consensus statement supported by the ASA may provide us with at least some of the answers. Continuing the theme of stroke the next article, also from this month’s JNSA, looks at the mortality during endovascular clot retrieval for ischaemic stroke. Timely considering the NASGBI involvement in newly published UK guidelines for the safe and effective management of these patients. Finally October’s Anesthesiology features both an editorial and manuscript looking at the handover process during anaesthesia. This is a familiar occurrence process to many neuroanaesthetists who often have to cope with long neurosurgical procedures. Much as we want a break or to get home do we have a responsibility to finish the case? Food for thought! Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative Care of Patients at High Risk for Stroke during or after Non-Cardiac, Non-Neurologic Surgery: Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care. JNSA 2014; 26: 273-85 The focus of this article is the identification, prevention and management of ischaemic stroke in adult patients undergoing noncardiac, noncarotid and non-neurological surgery. It was designed to be useful to anaesthetists, intensivists, surgeons and neurologists. This is a lengthy document but will prove useful for decision-making in this patient group. Having reviewed the available evidence the consensus document makes various recommendations, which include: 1. Identification of patients at high risk of stroke: Advanced age, renal disease and history of ischaemic stroke or TIA. 2. Timing of surgery and informed consent in patients with recent stroke: Consider delaying until aetiology determined and peak autoregulatory disturbance has passed following recent stroke (about 1 month). 3. Management of anticoagulants and antiplatelet drugs: Recent evidence suggests that continuation of aspirin in patients at risk of stroke after non-cardiac surgery is not indicated and may increase the risk of bleeding. 4. The role of preoperative ß blockers and statins: Continuation of ß blockers and statins is important for stroke prevention. 5. Recommendations regarding anaesthetic technique, intraoperative use of ß blockers, ventilatory strategies, blood transfusion, blood glucose and blood pressure management: Intraoperative hypotension should be avoided in patients at risk of stroke and for those in the beach chair position. 6. Management of acute stroke in the postoperative period: Neurology or stroke doctors must review surgical patients manifesting symptoms or signs of stroke urgently and neuroimaging is essential. Major noncardiac, non-neurological surgery is not an absolute contraindication to intravascular rtPa; mechanical thrombolysis is also an option for those at high risk of surgery related haemorrhage. Fenghua L, Deshaies EM, Singla A et al. Impact of Anesthesia on Mortality During Endovascular Clot Removal for Acute Ischemic Stroke. JNSA 2014; 26: 286-290# Best practice for endovascular clot retrieval remains controversial. Intra-arterial interventions such as intra-arterial thrombolysis and intra-arterial thrombectomy (IAT) are increasingly used for the treatment of acute ischaemic stroke. Anaesthesia may be required to reduce pain during mechanical thrombectomy, minimise movement, maintain physiological stability and for airway management. A cooperative and stationary patient will reduce intra-procedural and device related complications such as dissection, perforation and distal embolisation and this may be easier to achieve during general anaesthesia. Despite this recent studies have reported an association between general anaesthesia for intra-arterial thrombectomy and poor outcome. The authors reviewed practice in their institute for all acute stroke patients undergoing urgent IAT between December 2006 and October 2012. Practice changed during this period from routine GA with intubation and sevoflurane maintenance, before 2011, and routine conscious sedation (CS) with midazolam and fentanyl (to a target Ramsay sedation score of 2 to 3) after this. From 2011 intubation was only used in patients who required airway protection but even then maintenance was as with CS using midazolam and fentanyl. This transition was attributed to a the team becoming more comfortable with the use of CS but also a fear of time delays caused by the use of GA. Blood pressure was targeted in both groups to maintain a systolic of 160-200 mmHg. The authors found that GA along with hyperglycaemia to be significant predictors of mortality when compared with CS. However there are major limitations; this is yet another retrospective study which does not have the necessary data regarding stroke severity, size or location all of which will impact on patient outcome. We await a prospective, randomised trial to evaluate the effect of GA on outcome. Saager L, Hesler BD, Jing YMS et al. Intraoperative Transitions of Anesthesia Care and Postoperative Adverse Outcomes. Anesthesiology 2014; 121: 695-706 Dutton RP. Seamless Anesthesia Care. The Handover Process. Anesthesiology 2014; 121: 673-674 Transfers of patient care and responsibility between anaesthetists, or “handovers,” are common. However whether handovers worsen patient outcome remains unclear. These authors reviewed the records of 138,932 adult Cleveland Clinic (Cleveland, Ohio) surgical patients. They assessed the association between the total number of anesthesia handovers during a case and adjusted in-hospital mortality and major morbidities using multivariable logistic regression. Anaesthetic handovers were significantly associated with higher odds of a patient experiencing any major in-hospital mortality/morbidity. Each handover increased the risk of increased adverse postoperative outcome and it occurred no matter what the grade of anaesthesist. Cleveland clinic is a tertiary referral, academic unit so not dissimilar to a UK teaching hospital with a high number of long operations and sick patients. Although these results are probably not a surprise to us. Perhaps the size of the effect on adverse outcome is. However what should we do about it? The Cleveland clinic had no formal handover document; possibly this would have made a difference. Inevitably there will have to be handovers on occasions. What would be worse for the patient an exhausted, hungry anaesthetist or an effective handover? However there seems little doubt that the number of handovers should be kept to a minimum.