Trials Flashcards
CARP NEJM 2004
No difference in outcomes with or without preop CABG unless LM disease/EF <20%- don’t stent unless would already qualify
ENIGMA
N2O- hihger postop wound infeciton, fever, PNA, PONV, MI
POISE
High dose periop metoroprolol- lower risk MI/cardiac death, higher risk CVA and overall mortality
VISION
Peak TnI >20 ng/L a/w increased 30 day mortality
MANAGE Study- dabigatran caused reduction in mortality but bad study
Other studies- NT proBNP >300- increased mortality
METS
DASI vs physicain assessment of Fx capacity
- Physician assessment does not predict mortality or MI at 3/12 months
CPET- same, but did predict respiratory complications
DASI <34 a/w 30 day MINS/MI/complications
NT pro BNP predicted omortality
POISE 2
ASA in NCS- increased major bleeding, no change in death/non fatal MI/CVA
Clonidine- increased hypotension and non-fatal cardiac arrest, no change in death/MI
BRIDGE
Not bridging non-inferior to bridging for prevention of arterial thromboembolism
LMWH increased bleeding
Mean CHADS2 only 2.3, excldued mechanical valves’’
CODA, BALANCED sub study
Decreased depth of anaesthesia- lower POD and POCD.
Overall evidence mixed!
NAP 4 Airway
186 cases
In anaesthesia: poor assessment, planning for difficulty and airway ‘strategy’ and failure to plan for failure.
Inappropriate use of supraglottic airway device eg. aspiration risk, obesity
Reduced use of AFOI. ?Lack of skill/ confidence and poor judgement
In case of difficulty: repeated attempts not helpful/ needle CT failed in 60% of cases whereas surgical CT was universally successful
Aspiration was most common cause of death
1/3 adverse events occurred at emergence (eg. airway obstruction)
In ICU/ED: more likely to lead to permanent harm. Often during RSI. Failure to identify patients at risk, lack of skilled staff and equipment
Failure to use capnography contributed to 70% of deaths
Most common cause was dislodged tracheostomy or ETT. All patients should have emergency reintubation plan
NAP3 Neuraxial
Risk: paraplegia or death 1/50-100K, permanent nerve injury 1:25 - 50K
High risk groups: frail/old/epidural, anticoag, immunocomp
Prognosis: 2/3 severe injuries resolve
Learning points: monitor neurology, take limb weakness seriously (should resolve after 4 hours cessation, none in TEA), MRI/NSx ASAP when indicated
Specific learning points:
Vertebral canal haematoma
· 50% develop upon removal of epidural catheter
Spinal cord ischaemia
· Hypotension contributes
· MRI may not pick it up
Abscess
· May present after discharge
· May presents as sepsis without localizing symptoms or signs
· Material risk if >2 days, higher risk if >5-7 days
Obstetrics
· Post-neuraxial headache is probably simple PDPH
· But beware SDH and meninigitis if a) multiple attempts b) atypical headache
· Failed epidural top up followed by spinal causes unpredictable block height. Do CSE.
Wrong route
· Most common in obstetrics
· Keep trays separate
· Keep local connected to epi, or chuck it out (my note)
Cardiovascular collapse
· Must have IV fluid and vasoactives available if doing neuraxial
· Don’t do neuraxial in a hypovolaemic patient (my note)
Miscellaneous
· CSEs are overrepresented in complications and we don’t know why
NAP5 AAGA
Less frequent than previously reported: roughly 1/19000 (1/8000 with NMB and 1/136000 without)
High risk surgery cardiothoracic (1:8000) and C-sections (1:670)
2/3 occurred during dynamic phases (induction - RSI, difficult airway, obesity, NMB, thiopentone/ emergence - RMB)
1/3 in maintenance phase, 26% no cause found? resistance
Risk factors: single most important implicated in 93% - NMB. Use of TIVA with NMB highest risk (but only 23% had DOA monitoring)
Incidence lower in paeds
10% reports to NAP5 were due to drug error (MR given before induction agent)
NAP 6 Anaphylaxis
Incidence 1/10000 (true incidence may be 70% higher)
Hypotension > bronchospasm > oxygen desaturation > bradycardia > reduced/absent capnography
Antibiotics (47%) – Teicoplanin represented 12% exposures but caused 36% cases.
NMBA (33%) – similar incidences amongst NDMR. Sux twice as likely as others
Chlorhexidine 9%
Patent blue dye 4.5%
NMBD and antibiotics had rapid onset, chlorhex and patent blue dye were gradual
No incidence of latex anaphylaxis
Cardiac arrest was usually PEA
NAP7 Cardiac Arrest
Risk: complexity, morbidity, urgency, OOH
60% survive, 44% dc
Causes- haemorrhage, Brady, ischaemia
82% non shockable
Brady- highest resus
ASA 1-2 1:8000
DNACPR not suspended/followed
Unintended oesophageal intubation
Improvements
- Preop risk score
-Supervision of trainees
-Monitoring of Pts
-Drug dose/choice
anaesthetise in OT
Staff impact
