Article Notes
-
This quote is usually attributed to the Greek poet Archilochus, over 2,500 years ago... though today popularised by the US Navy SEALs! (and perhaps a few medical simulation specialists 😉) ↩
- Remifentanil infusions above 0.20-0.25 μg/kg/min are associated with hyperalgesia (OIH = Opioid Induced Hyperalgesia) and tolerance (AOT = Acute Opioid Tolerance) respectively.
- Some of these effects can be mitigated by multimodal analgesia (notably ketamine), and possibly by gradual weaning of a remifentanil infusion.
- The findings have been predominately identified in rats and volunteer human studies. The clinical and longterm significance is still uncertain.
- Although OIH and AOT arise from different physiological mechanisms, they are clinically difficult (if not impossible) to differentiate.
- The clinical priority for management is prevention.
A neat little study...
Gurus and team showed improvement in assertiveness and 'speaking up' behaviour among junior anaesthesia trainees, during a simulation workshop after exposure to a didactic session on speaking up behaviour – when compared to a control simulation group who did not receive the didactic session. (n=22)
The take-home message
There is likely benefit to explicitly discussing the issue of, and most importantly techniques for, speaking up when anaesthesia trainees witness management errors or oversights.
The one short-coming
The effects were only observed in a simulation environment, and while probably applicable to the more-consequential real world, as with much simulation research we are often dependent on surrogate markers of performance improvement.
Nonetheless, "we don't rise to the level of our expectations, we fall to the level of our training",1 right?
Daniel Jolley
Why is this important?
Suspicions that anesthetic technique impacts survival after cancer surgery continues to be both unanswered and psychologically weighty: are anesthetic choices undermining patient survival?
What did they do?
This Taiwanese research group conducted a retrospective cohort-study in a single hospital covering 10 years of elective hepatectomy patients, comparing propofol to desflurane anesthesia. Notably, hepatocellular carcinoma is one of the leading causes of cancer death in Taiwan.
And they found...?
TIVA propofol was associated with a dramatically better survival (hazard ratio 0.57 (0.38-0.59)), even in subgroup analysis dependent on staging.
Reality check
Although this finding is consistent with other observational studies across a range of cancers, the apparent size of the benefit (50% mortality reduction!) should give us pause.
Given inconsistent findings from a range of similar observational studies, it is unlikely that there is a real treatment effect of this magnitude.
While we await results from well-powered RCTs, the jury is still out on whether anesthesia choices impact any specific cancer surgery...
Daniel Jolley
Daniel Jolley
One of the earliest published case series linking post-operative hepatic necrosis to halothane anaesthesia.
We now know this occurs in about 1 in 10,000-30,000 adult halothane anaesthetics, and 1 in 60,000 in children, with a historical mortality of 30-70%. In 20% of cases the hepatitis is mild and self-limiting.
Daniel Jolley