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summary
1
Cutting to the chase...
This large, retrospective study with propensity-matched controls found NO difference in breast cancer survival between inhalataional and intravenous anesthetic techniques.
Why is this still important?
Following Exadaktylos' eye-popping 2006 retrospective, along with a few in vitro studies, anesthetists have been a little anxious that anesthetic technique choice could potentially have a such significant effect on cancer recurrence. To date, other trials have not replicated Exadaktylos' original results.
What was studied this time?
Yoo et al performed a retrospective study of 5,331 breast cancer patients over a 8 year period, looking at the relationship between anesthetic technique and both 5-year recurrence-free and overall survival.
There was no difference for either survival metric between inhalational or intravenous anesthesia.
So does this settle it?
Not yet. Although large and high quality, this is still a retrospective study with all the compromises that this brings.
Be smart
While we await results from prospective, randomized trials, we should not be distracted by the magical promise of one technique over another, and instead address the very real impact that anesthesia can have on patient Return to Intended Oncological Therapy (RIOT).
Yoo S, Lee HB, Han W et al. Total Intravenous Anesthesia versus Inhalation Anesthesia for Breast Cancer Surgery: A Retrospective Cohort Study. Anesthesiology. 2019 Jan 1; 130 (1): 31-40.
  Daniel Jolley
summary
1
This controversy-starting retrospective study reported a 30% reduction in 3 year recurrence-free survival after undergoing mastectomy for primary breast cancer in patients who received a traditional general anaesthetic with morphine analgesia, compared with those receiving a regional (paravertebral) technique.
Although plausible biological mechanisms have been suggested and even demonstrated in vitro, the huge treatment effect is yet to be replicated in better quality retrospective or prospective trials.

Evidence to date does not (yet) support this trial’s findings.
"An extraordinary claim requires extraordinary proof." – Marcello Truzzi
Exadaktylos AK, Buggy DJ, Moriarty DC et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006 Oct 1; 105 (4): 660-4.
  Daniel Jolley
pearl
1
In traumatic brain injury resuscitation with albumin is associated with a higher mortality than resuscitation with saline.
SAFE Study Investigators, Australian New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N. Engl. J. Med. 2007 Aug 30;357(9):874-84.
  Daniel Jolley
pearl
1
ICU resuscitation with either normal saline or 4% albumin results in similar outcomes, in the absence of traumatic brain injury.
Finfer S, Bellomo R, Boyce N et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N. Engl. J. Med. 2004 May 27;350(22):2247-56.
  Daniel Jolley
comment
0
Hmmm... not particularly helpful.
Lewis SR, Pritchard MW, Schofield-Robinson OJ et al. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery. Cochrane Db Syst Rev. 2018 Jul 18; 7: CD012584.
  Daniel Jolley
pearl
1
High troponin levels pre-operatively are associated with cardiac events and mortality after non-cardiac surgery.
Shen JT, Xu M, Wu Y et al. Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis. Eur J Anaesthesiol. 2018 Nov 1; 35 (11): 815-824.
  Daniel Jolley
pearl
1
Elective surgery should be delayed at least 9 months after stroke or cerebrovascular event, although there is a persisting increased risk of perioperative stroke in these patients.
Jørgensen ME, Torp-Pedersen C, Gislason GH et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA. 2014 Jul 16;312(3):269-77.
  Daniel Jolley
summary
1
Why this is interesting...
In many ways, human albumin might be the perfect colloid fluid – and concentrated 20% albumin could be the ideal resuscitation fluid in the critical care setting, where fluid overload is otherwise a common consequence. Because of its high relative concentration, the intravascular expansion effect of 20% albumin is roughly double its infused volume, unlike 4% or 5% albumin.
In the SWIPE trial Mårtensson et al showed that even in the leaky-capillary state of critical illness, resuscitation with 20% albumin decreased fluid needs, lessened positive fluid-balance states, and was not associated with harm when compared to 4-5% albumin.
What did they do?
This was a well designed multicentre trial across three adult Australian & UK ICUs. 321 patients were randomized to either 20% or 4-5% albumin resuscitation during their first 48h in ICU.
Bottom line:
Probably the most important takeaway is simply that resuscitation with 20% albumin is practical and results in no patient harm compared with 4-5%. The 576mL median lower difference in fluid balance is unlikely alone to be dramatically consequential.
Nonetheless an important first step before larger studies can look at morbidity and mortality outcomes.
Cautiously note though that for logistic reasons the trial was open label, so treating clinicians were well aware of which fluid they were using. Additionally, they were given free reign to choose additional resuscitation fluids (crystalloid or synthetic colloid) as the clinical situation required.
Mårtensson J, Bihari S, Bannard-Smith J et al. Small volume resuscitation with 20% albumin in intensive care: physiological effects : The SWIPE randomised clinical trial. Intensive Care Med. 2018 Nov 1; 44 (11): 1797-1806.
  Daniel Jolley
pearl
1
The intravascular expansion effect of 20% albumin is roughly double its infused volume, although 15% greater again in the healthy versus those with sepsis.
Margarson MP Soni NC. Changes in serum albumin concentration and volume expanding effects following a bolus of albumin 20% in septic patients. Br J Anaesth. 2004 Jun 1; 92 (6): 821-6.
  Daniel Jolley
summary
0
This update to their 2011 meta-analysis supports their conclusion that aspirin modestly reduces myocardial infarction when used for primary prevention, but at the expense of increased risk of intracranial and major bleeding.
Raju N, Sobieraj-Teague M, Bosch J et al. Updated Meta-Analysis of Aspirin in Primary Prevention of Cardiovascular Disease. Am. J. Med. 2016 May 1; 129 (5): e35-6.
  Daniel Jolley