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A useful review of the role of rehabilitation in frail patients by Milder, Pillinger and Kam.
• They note that there is no gold standard to measure frailty, although there are many attempts to reliably identify and measure frailty across its many domains.

• Nonetheless frailty is strongly associated with perioperative morbidity and mortality.

• One proposed indicator of physical frailty is the presence of three of Fried's five factors: unintentional weight loss; grip strength weakness; exhaustion; slow walking speed; and low physical activity.

• Frailty is "...a multidimensional state of reduced physiological reserve, resulting in increased vulnerability to stressors, decreased resilience, and loss of adaptive capacity."

• Prehabilitation aims to increase physiological reserve through pre-operative intervention, including but not limited to exercise, nutrition and inspiratory muscle training.
Final word: although attractive, prehab has not yet been shown to improve outcomes in frail patients, though this is likely due to the absence of high quality studies.
Milder DA, Pillinger NL, Kam Peter C A PCA Department of Anaesthetics, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia. . The role of prehabilitation in frail surgical patients: A systematic review. Acta Anaesthesiol Scand. 2018 Nov 1; 62 (10): 1356-1366.
  Daniel Jolley
summary
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• β-lactam allergy, particularly penicillin allergy is the most common perioperative patient-reported sensitivity, in up to 35% of patients.
• Unneccessary switching to non-β-lactams for surgical prophylaxis is not cost-free, and is contributing to the rise of c. difficile and vancomycin-resistant Enterococcus (VRE).

• Patient history of penicillin allergy is of variable quality, and often does not allow the allergy to be ruled-out.

• Step 1 – differentiate drug side effects from allergy. Isolated nausea, vomiting or diarrhoea are usually side effects.

• Step 2 – identify the type of hypersensitivity.

  • Most drug reactions are Type 4 (T-cell mediated), delayed from 2 hours to days after exposure. Mostly benign cutaneous symptoms (eg. rash) that do not necessarily require avoiding future β-lactam exposure, except in the case of Stevens-Johnson syndrome.
  • Type 1 (IgE-mediated) hypersensitivities are immediate (minutes to 2 hours) but less common, causing urticaria, angioedema and/or anaphylaxis. Future exposure should be avoided.
  • Type 2 (cytotoxic) and Type 3 (immune complex) are much less common, and present with more serious, though delayed, reactions (days to weeks).

• Take home: Mild symptoms (eg. rash developing more than 2h after exposure) probably do not require β-lactam avoidance. If there is a history of moderate or severe reaction, then avoiding all β-lactams is wise.

• Of interest: Although R1 side-chain similarity is the main contributor to penicillin-cephalosporin cross-reactivity, importantly, 1st generation cephazolin has a different R1 side-chain and has been reported to not cross-react. Other cephalosporins share side-chains with specific penicillins.

• Finally, stop giving IV test doses. It makes no sense from a safety point of view and offers no useful information.
Hermanides J, Lemkes BA, Prins JM et al. Presumed β-Lactam Allergy and Cross-reactivity in the Operating Theater: A Practical Approach. Anesthesiology. 2018 Aug 1; 129 (2): 335-342.
  Daniel Jolley
pearl
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Epidural fentanyl does not have an effect on breastfeeding initiation.
Wilson MJ, MacArthur C, Cooper GM et al. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia. 2010 Feb 1;65(2):145-53.
  Daniel Jolley
pearl
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Routine preoperative echocardiography before operative repair of hip fracture does not reduce mortality or postoperative complcayions.
Yonekura H, Ide K, Onishi Y et al. Preoperative Echocardiography for Patients With Hip Fractures Undergoing Surgery: A Retrospective Cohort Study Using a Nationwide Database. Anesth. Analg. 2019 Feb 1; 128 (2): 213-220.
  Daniel Jolley
pearl
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Perioperative clonidine administration does not reduce mortality or myocardial infraction, but does increase the risk of hypotension and non-fatal cardiac arrest.
Devereaux PJ, Sessler DI, Leslie K et al. Clonidine in patients undergoing noncardiac surgery. N. Engl. J. Med. 2014 Apr 17; 370 (16): 150415131504-13.
  Daniel Jolley
pearl
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Ondansetron, dexamethasone, droperidol and total intravenous anesthesia (TIVA) all have a roughly similar, productive effect to reduce postoperative nausea and vomiting (PONV) by about one third.
Apfel CC, Korttila K, Abdalla M et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N. Engl. J. Med. 2004 Jun 10; 350 (24): 244124512441-51.
  Daniel Jolley
pearl
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BIS monitoring may not reduce the incidence of awareness under general anesthesia.
Avidan MS, Zhang L, Burnside BA et al. Anesthesia awareness and the bispectral index. N. Engl. J. Med. 2008 Mar 13;358(11):1097-108.
  Daniel Jolley
pearl
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The incidence of awareness-with-recall under general anesthesia in the United States is 1-2 cases per 1,000 patients.
Sebel PS, Bowdle TA, Ghoneim MM et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth. Analg. 2004 Sep 1;99(3):833-9, table of contents.
  Daniel Jolley
pearl
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Perioperative epidural analgesia in high-risk patients undergoing major abdominal surgery improves analgesia but does not have other morbidity or mortality benefits.
Rigg JR, Jamrozik K, Myles PS et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002 Apr 13; 359 (9314): 127612821276-82.
  Daniel Jolley
pearl
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Intraoperative warming of patients avoids hypothermia, reduces wound infection and shortens hospital stay after colorectal surgery.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N. Engl. J. Med. 1996 May 9;334(19):1209-15.
  Daniel Jolley