Parien' JJ, Mongardon N, Megarbane B et al. Intravascular Complica'ons of Central Venous Catheteriza'on by Inser'on Site. New England Journal of

Transcription

1 Parien' JJ, Mongardon N, Megarbane B et al. Intravascular Complica'ons of Central Venous Catheteriza'on by Inser'on Site. New England Journal of Medicine 2015; 373:

2 The Study 3SITES Study Mul'na'onal, randomised, trial designed to answer the ques'on: the risk of catheter-related bloodstream infec'on or symptoma'c catheter-related deep-vein thrombosis rela'ng to site of inser'on in adult pa'ents who had been admired to an intensive care unit (ICU)

3 Importance/relevance Central lines have associated morbidity from infec'on, inser'on complica'ons and thrombo'c events Catheter-related blood stream infec'ons increase morbidity, mortality and healthcare costs Concerns regarding subclavian and PTX risk especially cf low rate in IJV with USS guidance Thrombo'c risks uncertain, but of worry in certain popula'ons e.g. renal pa'ents

4 Popula'on: 10 ICUs in France Methods (PICO) 3471 catheters were inserted in 3027 pa'ents 1016 subclavian, 1284 IJV, 1171 femoral Eligibility criteria > 18 years, admired to ICU and needed CVC At least 2 or 3 sites available Exclusion criteria Only one site available CVC expected to be removed outside ICU

5 Methods (PICO) Interven'on CVC inser'on IJV, subclavian or femoral site Full asepsis Landmark or USS (USS encouraged, but also included marking then landmark) Control: Nil

6 Methods (PICO) Outcome: Primary Incidence of major CVC complica'ons within 48 h Thrombo'c (screened with USS) or CRBI SCV 1.5 vs. IJV 3.6 vs. FEM 4.6 [per 1000 catheter-days] Pairwise SCV best, IJV FEM Secondary Incidence of major CVC inser'on complica'ons PTX: SCV 1.5% vs. IJV 0.5% [NNH 100]

7

8 Valid study? Were pa'ents randomised? YES Stra'fied and 1:1 or 1:1:1 Was randomisa'on concealed? NO Unable to blind CVC site Were pa'ents analysed in the groups to which they were randomised? YES Were groups similar? YES Well matched on admission including immunosuppression and SAPS score

9

10 Valid study? Were pa'ents, clinicians, and outcome assessors aware of group alloca'on? NO Was follow up complete? YES

11 Do I need to change my prac'ce? Not as a UK anaesthe'st in STH Unblinded Range of an'bacterial precau'ons Why a composite complica'on measure? USS not randomised or mandated Landmark: SCV 86% IJV 33% FEM 74% Failure: SCV 15% IJV 8% FEM 5% Study needs repea'ng with USS for FEM/IJV to assess true inser'on complica'on rate

12 Wigmore TJ, Mohammed K, Jhanji S. Long-term Survival for Pa'ents Undergoing Vola'le versus IV Anesthesia for Cancer Surgery: A Retrospec've Analysis. Anesthesiology 2016; 124: 69-79

13 The Study Single centre retrospec've review designed to answer the ques'on: what is the associa'on of anaesthe'c technique (vola'le vs TIVA) with long-term survival in pa'ents having elec've surgery in a UK cancer centre?

14 Importance/relevance General anaesthe'c drugs may influence defences against malignancy. Vola'le agents may: Decrease func'on of natural killer cells Up regulate hypoxia-inducible factors (HIF) Increase insulin-like growth factor (IGF)

15

16 Popula'on: Royal Marsden Eligibility criteria Methods (PICO) Aged > 16 years Having elec've surgery June 2010 to May 2013 Anaesthe'c according to anaesthe'st s preference No nitrous oxide used Exclusion criterion If TIVA and vola'le both used during the study period

17 Methods (PICO) Interven'on Nil Comparator: Vola'le (n=3316) 21% remifentanil; 19% isoflurane; 79% sevo TIVA (n=3714) Propofol plus remifentanil Propensity matched at baseline

18

19 Methods (PICO) Outcome: Hazard ra'o 1.46 (95% CI ) for vola'le

20

21 Do I need to change my prac'ce? Not at the moment Need prospec've RCT to prove causa'on rather than associa'on

22 Do I need to change my prac'ce? Not at the moment Need prospec've RCT to prove causa'on rather than associa'on Did not control for depth of anaesthesia

23 Do I need to change my prac'ce? Not at the moment Need prospec've RCT to prove causa'on rather than associa'on Did not control for depth of anaesthesia Effect of individual anaesthe'st?

24

25 Do I need to change my prac'ce? Not at the moment Need prospec've RCT to prove causa'on rather than associa'on Did not control for depth of anaesthesia Effect of individual anaesthe'st? No correc'on for tumour staging

26 Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Periopera've Complica'ons in Obstruc've Sleep Apnea Pa'ents Undergoing Surgery: A Review of the Legal Literature Anesthesia & Analgesia 2016; 122:

27 The Study Retrospec've review of legal literature of cases involving pa'ents with known or suspected OSA to determine: the legal ramifica'ons and medicolegal burden associated with poor outcomes in OSA pa'ents having surgery.

28 Importance/relevance OSA pa'ents has increased adverse outcomes especially dead in bed 25% of men, 10% of women Uncertain how to manage peri-opera'vely Defer pending sleep studies/cpap? Crack on and go to HDU?

29 STOP-BANG at STH S. Do you snore loudly enough to be heard through a closed door? Pa'ents who do not snore are unlikely to have OSA. T. Do you feel 'red or during the day 'me, every day? O. Has anyone observed you stop breathing during sleep? P. Do you have high blood pressure (established or new)? B. Body mass index of over 35 kg m -2 A. Age over 50 years N. Neck circumference of >40 cm (16 inches) G. Male gender.

30

31 Popula'on: Methods (PICO) Retrospec've review of three legal databases to cases per annum in US Included 1991 to 2010 ( cases) Eligibility criteria > 18 years, with known/suspected OSA Surgical mishap directly implica'ng OSA Exclusions Cases serled out of court Surgical mishap directly implica'ng OSA

32 Methods (PICO) Interven'on Nil Control: Nil

33 Methods (PICO) Outcome: 24 cases (92% elec've) General surgery 33.3%; ENT 37.5% Death 45%; anoxic brain injury 45% Intra-op 21%; PACU 33%; Ward 46% All ward pa'ents received postopera've opioids and had an unwitnessed arrest $2.5 million on average

34 Do I need to change my prac'ce? In USA these cases are increasing although malprac'ce suits are falling Underes'mates true numbers ASA have produced guidance (2014)