how can anesthesia improve surgical patient outcomes? surgeons are great at putting things back...
TRANSCRIPT
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How can Anesthesia Improve Surgical Patient Outcomes?
• Surgeons are great at putting things back together:– Reducing fractures– Anastamosing bowel– Approximating skin edges
But then we need to work together to create the right conditions for healing to occur…
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Anesthesia - a Leader in Safety
Anesthesia death rate for ASA 1 patients is now 4 per million.
The “Six Sigma” target for factories is 3.4 errors per million events.
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CMPA Dues
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Better equipment
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Better drugs
• HALOTHANEHALOTHANE• CURARE CURARE • PENTOTHAL PENTOTHAL • DEMEROL DEMEROL
And soon …..And soon …..• NEOSTIGMINENEOSTIGMINE
• SEVO & DES• ROCURONIUM• PROPOFOL• HYDROMORPHONE & ALFENTANIL
SUGAMMADEX
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Better education
MEETINGS& WORKSHOPS
CAS and ASA Annual Meetings
Ontario Anesthesia Meeting
McGill Course
… and many others
WEB SITES
GASNet
Virtual Anesthesia Textbook
NYSORAwww.neuraxiom.com
www.thoracic- anesthesia.com
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Preoperative Medications
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βeta Blockers 1990-2000
• Numerous studies showed– ↓ incidence of postop ischemia– ↓ incidence of perioperative MI– ↓ cardiac mortality
• β-Blockers became the craze
• 3 supporting editorials in NEJM – One even suggested that β-blockers might be
better than preop revascularization in high risk patients!!!
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βeta Blockers 2000-2006
• 2 large RCTs showed no reduction in 30 d and 6 mo cardiac event rates
• Similar study in patients with DM – No beneficial effects of β-blocker therapy
• Why?– Inadequate β-blockade? – Low risk patients?– Better overall preoperative care than 1990?
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β-Blockers 2007Where do we stand now?
• Withdrawal of β-blockers preop is BAD– 2007 study showed 2.6X increased 1 year
mortality when β-blocker was stopped preop.
• High risk patients probably benefit more than low risk patients (prev. MI, poor LVF)
• Appropriate dose– Target HR should be <70 preop– Lower risk of cardiac events with low HR.
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Statins 2004-2006
• Now thought to have properties beyond lipid lowering effect.– Plaque stabilizing effect?– Decrease vascular inflammation?
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Statins 2004-2006
• Several recent studies suggest statins are cardioprotective– Lower incidence of cardiac events– Decrease length of stay– Decrease incidence of perioperative strokes
• Metanalysis BMJ 2006 (2 RCTs + 15 cohort studies)
– Statin users had lower incidence of death and acute coronary syndromes
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Statins 2007
• Where do we stand in 2007?– There’s probably something there– Not enough data to recommend routine use– We don’t know which patient population will
benefit most.
• Await results of DECREASE IV trial– 6000 moderate and high risk patients
randomized to b-blockers, statins or both.
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Stop Smoking forSafer Surgery• We know smoking is a risk factor, but we are complacent about it.
NOTE:Smoking decreases tissue oxygenation, interferes with wound healing and impairs surgical outcome.Even brief interventions work sometimes.Patients can be referred for help to stop.Safer Healthcare Now makes advice to stop smoking a required part of the treatment of Acute MI.
All smokers should be advised to stop smoking preoperatively.
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Template
• 6 – 8 hours of non-smoking reduces CO levels
• “NPO after MN”• “No smoking after
Midnight”
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Safer Healthcare Now
• SHN is the Canadian version of a US campaign to reduce medical errors, improve and standardize care, prevent hospital-acquired infection, and save lives.
• Looked for “low hanging fruit” – the relatively quick and easy fixes.
• Data-driven, solidly researched.• Six major areas chosen, including two
related to anesthesia:
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Central Line Infection
• In USA, 48,600 central line infections, possibly 17,000 deaths.
• 2/3 are preventable with simple precautions.
• Extrapolating to Canada, this could save over 1,000 lives per year.
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Central Line Infection
• Central Line Insertion:– Prep with 2% chlorhexidine in alcohol– Scrub hands – Mask, hat, gown and gloves– Wide sterile field– Consider subclavian route
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Reducing Surgical Site Infection:
• Antibiotics start 1 hr preop, finish before incision. Usually only one dose.
• Perioperative blood sugar level <11.1mmol/l in cardiac cases.
• Core temp. >36 degrees in major cases.
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“Mild Hypothermia”
• Core 34 – 36 degrees
• Very common
• Early– Redistribution of heat from core to periphery.
• Late– Heat loss, convection, evaporation, cold fluid.
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Effects of Mild Hypothermia• Cardiac - Incr Norepinephrine Incr BP
– Angina, MI, Arrest 2% v 10% if cold– ECG Abn (Isch, VT) 7% v 16 % if cold
• Coagulation– Decr platelet funct’n, Incr PTT PT @ pt temp– Double blood loss, 500 ml more
• Infection– Vasocon, Decr Tissue O2– Decr antibody production– Decr neutrophil function
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Studies of Temp and Infection
NORMOTHERMIA HYPOTHERMIA
TEMP 36.6 34.7
INFECTIONS 6% 19%
Sutures in one day longer, LOS 2.6 days longer in hypothermia group
KURZ Colorectal Surgery
MELLING Clean minor surgery
NORMOTHERMIA HYPOTHERMIA
INFECTIONS 5% 14%
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What to do?
• Preheat patients
• Avoid heat loss
• Cover up (doesn’t matter with what)
• Warm IV solutions
• Forced air warming over maximum surface area
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Regional Anesthesia and Patient Outcome
Regional anesthesia is the standard for:
• CSection (spinal/epidural)
• Epidural for AAA
• Thoracic Epidural for Lung Surgery
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The Benefits of Regional Anesthesia
• Avoid the major physiologic trespass associated with GA
• Rapid recovery Cardiac depression Respiratory depression PONV Ileus Blood loss Thromboembolism Post-operative pain control
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Proven Results of Regional
• Quicker wake –up
• Shorter PACU Stay
• Earlier Ambulation
• Quicker Rehab
• Improved patient satisfaction
• Shorter Hospital Stay
• Less M & M
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Is Regional for Everybody?
• It depends..– For low risk patients: probably no benefits,
except for improved patient satisfaction
– For intermediate and high risk patients, proven less morbidity and mortality for all major organ systems except CARDIAC
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CONCLUSION• Advances in anesthesia have already made
surgery much safer.• We can do more to perfect preoperative
preparation, prevent infection, & provide optimum conditions for healing.