Advanced care plans in the peri-operative period

For many, the COVID-19 pandemic brought the stark reality of our mortality into focus. Along with the controversial application of ‘blanket’ DNACPR orders, it has forced all in the profession to consider how we involve our patients in the difficult conversations and decisions regarding end-of-life care. The development of the ReSPECT process by the Resuscitation Council (UK) encourages patients in the community and hospital to create personalised recommendations for clinical care if they are unable to make or express their choices in a future emergency. In view of the changing landscape of advance care planning, the Association of Anaesthetists has created guidelines on implementing advance care plans in the peri-operative period. This is a consensus document produced by expert members of a working party and endorsed by the Resuscitation Council (UK) and Compassion in Dying. It highlights that advance care plans are to allow for patient-centred outcomes, and clarifies how to discuss, and deal with, DNACPR decisions in the peri-operative period. 

Continuing with the theme of patient-centred outcomes, this important systematic review and meta-analysis by McPeake et al. looked at hospital readmission after critical care and found that over 50% of previous critical care patients were readmitted to hospital within one year. Risk factors included co-morbidities, delirium, mechanical ventilation during the initial admission and infection after discharge. In the associated editorial, Plummer and Lonecomment on how these risk factors might be modified, and if so, what interventions are appropriate and possible. We all too often do not think past mortality for our outcomes; this study highlights how critical illness impacts patients, their families and healthcare resources, and states the case for targeted interventions for at-risk critical care survivors to reduce morbidity post-discharge. 

Clearly you should never judge an article purely by its title but ‘Regional analgesia following caesarean section: new kid and a block?’ is as incisive as an editorial as its title is witty (especially if you are a child of the 80-90’s). Kearsley et al. provide comment on a network meta-analysis performed by Singh et al. looking at the efficacy of regional blocks or local anaesthetic infiltration for caesarean section analgesia. Using a random effects Bayesian model they performed a network meta-analysis including 8730 parturients and found that bilateral ilio-inguinal blocks provided the highest reduction in 24-hour morphine equivalents, regardless of whether intrathecal morphine was administered. The associated editorial suggests that perhaps the time for transversus abdominus plane blocks is over and that ilio-inguinal blocks could be added to the RA-UKs Plan A blocks; but also appreciate the resource implication this may have as ilio-inguinal blocks require ultrasound provision. Step by step regional analgesia for caesarean section is becoming clearer.

One article that has garnered a lot of social media debate is a randomised controlled trial of a novel tramadol chewable tablet: pharmacokinetics and tolerability in children. Yoo et al. formulated a chocolate-flavoured tramadol tablet and performed a pilot RCT in a single centre. The chocolate tramadol tablet was found to have a higher bioavailability, quicker absorption and be better tolerated than liquid tramadol (Fig. 1). 

Figure 1 Taste tolerability scores obtained from children, parents and nurses for (A) the tramadol chocolate-based drug delivery system tablet and (B) tramadol liquid formulation. The 5-point facial hedonic scale was: 1 = dislike very much; 2 = dislike a little; 3 = not sure; 4 = like a little; and 5 = like very much.

If tramadol isn’t your paediatric analgesic of choice, Saffer et al. present a randomised controlled trial comparing oral paracetamol with water versus just water 1 h pre-operatively. They found that, in 97 children aged between 1 and 96 months, there was no significant difference in either gastric aspirate volume or pH between the groups. The authors acknowledge that some centres may already give pre-operative oral paracetamol, but this study provides reassurance that with reducing fasting times, pre-operative oral paracetamol is a safe alternative to the more expensive intra-operative intravenous option. 

Following on from last month’s consensus statement on academic publishing of papers from low-to-middle-income countries, Stahlschmidt et al., present a convincing before and after cohort study on enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil. They created a 48-hour post-operative care bundle (Fig. 2) and demonstrated that increased surveillance of these high-risk patients reduced 30-day mortality. Enhanced post-operative surveillance of high-risk patients is potentially viable for use in other LMIC settings where critical care resource is scarce.

Figure 2 High-risk bundle compliance evaluation.

This month also sees the publication of an randomised controlled trial of a text message intervention to reduce burnout amongst trainee anaesthetists. No significant difference was demonstrated between trainees who received fortnightly text messages based on behavioural techniques to reduce burnout and those who did not. However, exploratory post-hoc analysis did demonstrate that burnout symptoms were reduced in trainees identified as having personal or work-related difficulties, and those particularly affected by the pandemic. Importantly, the authors found that there was no backfire effect which makes this a safe intervention. It is unfortunate that studies such as this are having to be performed, and the associated podcast discusses some of the factors surrounding trainee burnout.

Elsewhere, we have a retrospective cohort study on obstetric anaesthesia and analgesic practices for in SARS-CoV-2 positive patients; a service evaluation on the effect of transfer from critical care areas for mechanically ventilated SARS-CoV-2 patients; an editorial with practical tips on how we, as anaesthetists, can contribute towards combatting the global heating emergency and an editorial on the future of space anaesthesia!

Finally, attention now shifts to meeting again face-to-face later this year in Belfast. Booking for Annual Congress 2022 is now open! We are very much looking forward to seeing you there.

Cara Hughes and Andrew Klein