Quick Journal Club - ESRA

ESRA Updates

June 2021 | Issue 05

Quick Journal Club

Brian O’Donnell (BreastCheck and Cork University Hospital, Ireland) @briodnl
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For this edition Dr Brian O’Donnell was asked to select one (or more) article(s) which for him were/are important, interesting or changed his clinical practice. This choice can be a general big randomized study but can also be very personal.
Dr Brian O’Donnell does not need a lot of introduction. He is a leading expert in anaesthesia and a fantastic tutor and lecturer. It is with great pleasure that we like to share his contribution for this journal club.

There’s little doubt that the global pandemic flipped our collective personal and professional lives at a weird dystopian angle. Notwithstanding the phenomenon of Covid-related information, the anaesthesia literature contributed significantly to my professional growth and has influenced my day to day clinical practice. I will probably remember 2020 for three key publications on the topic of prehabilitation and frailty, intraoperative blood pressure control and long awaited anaesthesia guidelines for hip fracture care.

Prehabilitation can be thought of as a multidisciplinary process to: (1) identify patients at greatest risk of adverse clinical outcome following surgery; and (2) to optimise nutritional, lifestyle (smoking cessation, alcohol modification etc) and cardiorespiratory fitness in the days and weeks prior to surgery. As an anaesthesiologist with interests in both regional anaesthesia and perioperative medicine, I frequently encounter older frail people presenting for cancer and non-cancer surgery at our perioperative assessment clinic. Prehabilitation may have a significant role in managing and mitigating risk in this cohort of patients. Frailty was the topic of the June 2020 edition of journal Anesthesia and Analgesia. Norris and Close provide a balanced review of the role of prehabilitation in managing perioperative risk and enhancing patient outcome in older people with frailty syndrome [1].

Hypotension has long been accepted as an inevitable consequence of both general and neuraxial anaesthesia. The impact of hypotension on clinical outcome is poorly understood. A noteworthy example is the relationship between cerebral autoregulation, cerebral blood flow and mean arterial pressure. The accepted critical threshold of 50 mmHg [2] is at best an over-simplification and at worst a potential contributor to cerebral hypo-perfusion during anaesthesia [3]. The Perioperative Quality Initiative (POQI https://thepoqi.org), an international multidisciplinary organization with interests related to perioperative medicine, published a series of consensus articles on the physiology of blood pressure and the optimisation of pre-, intra-, and postoperative blood pressure [4,5,6,7]. While each of these articles are worth reading, the article describing the association between intraoperative hypotension and the occurrence of harm has had greatest impact on my clinical practice [6]. I now aggressively treat all episodes of hypotension and I no longer tolerate systolic blood pressure of less than 100mmHg or mean arterial pressure of less than 65mmHg.

Evidence based clinical standards for the provision of better anaesthesia and analgesia for patients undergoing hip fracture anaesthesia have been published [8]. The integration of these standards into clinical practice causes significant challenges in terms of challenging established practices of individuals (clinicians and patients) and healthcare institutions. The Association of Anaesthetists 2020 guideline document provides an excellent oversight into the establishment of patient-outcome centred perioperative care for patients with neck of femur fracture [9]. Evident within this document is a focus on ‘what matters most’ to the patient, the integration of a multidisciplinary approach to patient care and the alignment of service provision to meet patient needs.


References:

  1. Norris CM, Close JCT. Prehabilitation for the Frailty Syndrome: Improving Outcomes for Our Most Vulnerable Patients. Anesth Analg 2020;130:1524–33.
  2. Willie CK, Tzeng YC, Fisher JA, Ainslie PN. Integrative regulation of human brain blood flow. J Physiol. 2014;592:841–859.
  3. Drummond JC. Blood pressure and the brain: hoe low can you go? Anesth Analg 2019;128:759–71.
  4. Ackland GL et al. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. British Journal of Anaesthesia 2019 122:542-551.
  5. Sanders RD et al. Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery. British Journal of Anaesthesia 2019 122:552-562.
  6. Sessler DI et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. British Journal of Anaesthesia 2019 122: 563-574.
  7. McEvoy MD et al. Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery. British Journal of Anaesthesia 2019 122: 575-586.
  8. Stuart M White in http://www.hipfractureanaesthesia.com/standards-2/
  9. Griffiths R et al. Guideline for the management of hip fractures 2020. Anaesthesia 2021, 76, 225–237.
Topics: Top articles , Hip fracture repair , Hypotension , Regional Anaesthesia , Recovery , Journal club

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