Monthly Archives: January 2014

Three Perioperative Interventions Do Not Affect Quality of Life

 

Anesthesiology_January2San Francisco—The administration of steroids in the perioperative period, tight glucose control during surgery and light anesthesia do not affect patient quality of life measured at 30 days after major noncardiac surgery, a new study shows.

Although previous studies have found an association between steroids and improved quality of life (QoL) after cardiac surgery, results of the DeLiT (Dexamethasone, Light Anaesthesia, and Tight Glucose Control) randomized controlled trial failed to support those results. Also of note, this is the first and only randomized trial to date to study tight versus conventional glucose control in noncardiac surgery patients.

“Initially, investigators were under the impression that tight glucose control is beneficial,” said Basem Abdelmalak, MD, associate professor of anesthesiology and director of anesthesia for bronchoscopic surgery at Cleveland Clinic in Ohio. “Dexamethasone is currently being used for postoperative nausea and vomiting prophylaxis, or to help decrease airway edema in airway surgery.” However, this study did not show either intervention to be beneficial. Dr. Abdelmalak presented the results of his team’s study at the 2013 annual meeting of the American Society of Anesthesiologists (ASA; abstract 4168).

Previous work indicates that high-dose steroids improve QoL after cardiac surgery; it also indicates that intensive glucose control reduces sepsis and improves mortality outcomes in some patient populations, according to the researchers. Anesthesia guided by bispectral index monitoring (BIS; Covidien) reportedly speeds recovery and reduces respiratory complications as well as nausea and vomiting. The investigators thus expected to demonstrate beneficial effects of each tested intervention, Dr. Abdelmalak said.

The study consisted of 326 patients scheduled for noncardiac surgery under general anesthesia. They were randomized to receive 14 mg of IV dexamethasone tapered over three days versus placebo, intensive versus conventional glucose control (blood sugar goal of 80-110 mg/dL vs. 180-200 mg/dL), and light (BIS target 55) versus deep anesthesia (BIS target 35).

The researchers assessed QoL using the SF-12v2 Health Survey, a shorter version of the SF-36v2, obtaining scores preoperatively and 30 days after surgery. The researchers evaluated the effect of each intervention on physical and mental components of the survey.

After adjusting for minor differences in baseline ASA physical status, type of surgery and history of congestive heart failure and coronary artery disease, the researchers found no difference for any intervention on physical or mental SF-12v2 scores 30 days after surgery (P>0.4 for all).

Quality of life was a secondary outcome for DeLiT. The recently published primary results of the study, based on a composite of serious complications, showed no significant effect on perioperative morbidity from any of the three treatments (Table; Br J Anaesth 2013;111:209-221).

“Given that none of the interventions influenced the primary outcome, it is perhaps unsurprising that there was also no effect on quality of life. It remains possible, though, that a larger dose of steroid may yet prove effective,” said Daniel I. Sessler, MD, the senior investigator on the study and director of outcomes research at the institution.

“There is increasing interest in quality of life as a primary or secondary end point in large perioperative trials, as researchers realize that survival is not the only outcome that is valued by patients and their carers,” said Kate Leslie, professor and head of Anaesthesia Research at the Royal Melbourne Hospital in Melbourne, Australia, who was not involved in the work. “The investigators tested three perioperative interventions with the potential to improve quality of life after surgery. Although none were shown to improve quality of life, these data provide a suitable basis for further study of different doses of dexamethasone and other anti-inflammatory treatments.”

 

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Clinical+Anesthesiology&d_id=1&i=January+2014&i_id=1030&a_id=24705

 

 

 

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General Anesthesia Linked to Language Problems in Children

_December2San Diego—Surgery with general anesthesia in young children may well lead to diminished language abilities and cognition, not to mention long-term regional volumetric alterations in brain structure, recent research suggests. Whether these findings are due to the anesthesia or some other mitigating factor, however, remains to be determined in a prospective trial.

Animal studies have shown that anesthetic exposure early in life leads to structural and functional abnormalities of the brain. But epidemiologic studies have been unable to determine whether this phenomenon also occurs in humans.

Andreas W. Loepke, MD, PhD, and his colleagues from Cincinnati Children’s Hospital Medical Center, compared children who were exposed to anesthesia before their fourth birthday (n=52) with those not exposed to the agents (n=52). Groups were matched for age, sex, handedness and family income. Neurocognitive assessments included tests of language skills and intelligence. Structural brain evaluations were performed using T1-weighted MRI scans.

“Most were [ear-nose-throat] procedures done under halothane or sevoflurane,” said Dr. Loepke, associate professor of anesthesiology at the University of Cincinnati, who presented the findings at the 2013 annual meeting of the International Anesthesia Research Society (IARS; abstract S-316). “The exposure was usually between the first and second years of life, and all of the patients were generally healthy.”

The researchers found that although average test scores for both groups were within population norms, the previously exposed children scored lower in all tests (Table 1). More specifically, exposed patients were statistically significantly worse with respect to listening comprehension, expressive language and measures of IQ.

Table 1. Neurologic Test Results for Children Exposed or Not Exposed to Anesthesia

Test

Exposed (n=52)
Mean±SD

Not Exposed (n=52)
Mean±SD

Differences
Mean±SD

P Value (=)

95% Confidence Interval

OWLS Listening

101.19±12.92

107.15±11.50

5.96±16.86

0.013

1.31-10.6

OWLS Oral Expression

108.06±13.31

111.40±15.50

3.34±21.20

0.257

-2.5-9.18

OWLS Oral Composite

104.66±12.23

110.11±13.77

5.45±19.17

0.043

0.17-10.74

WISC/WAIS Verbal

111.55±12.72

114.89±12.99

3.34±18.01

0.183

-1.62-8.3

WISC/WAIS Performance

108.32±14.53

114.72±13.08

6.40±17.66

0.011

1.53-11.26

WISC/WAIS Full Scale

110.89±13.41

116.25±13.10

5.36±17.90

0.034

0.42-10.29

OWLS, Oral and Written Language Scales; SD, standard deviation; WAIS, Wechsler Adult Intelligence Scales; WISC, Wechsler Intelligence Scale for Children

“We then used an overlay of the patients’ MRIs to examine clusters of brain cells that were different between the exposed and unexposed cohorts,” Dr. Loepke said. The volume of gray matter was sporadically reduced in posterior brain regions of previously exposed children; lower IQ correlated with reduced gray matter volume in the precentral gyrus.

Although the findings seem to indicate that exposure to general anesthesia in early childhood leads to diminished language abilities and cognition, Dr. Loepke was uncomfortable making a causal relationship based on his group’s data.

“We still don’t know if these findings are due to anesthetic exposure, postoperative pain or the inflammatory response to the surgery,” he explained. “This is just a retrospective analysis, so we just have to take it as another piece in the puzzle.”

Dean B. Andropoulos, MD, chief of anesthesiology at Texas Children’s Hospital in Houston, cited yet another possible confounder. “There is a paper from the [ear-nose-throat] literature recently that says if a child suffers prolonged obstructive sleep apnea [OSA] during surgery, it has a detrimental effect on long-term neurodevelopmental outcomes,” Dr. Andropoulos said. “So we need to keep looking at confounding variables. Don’t leap to the conclusion that these results are purely due to the anesthetic agent itself. And obviously we know that a young child having a tonsillectomy will usually have a certain degree of OSA.”

If exposure to general anesthesia appears to raise a child’s risk for downstream cognitive problems, spinal anesthesia (SA) seems to be relatively benign, according to results from another study researchers presented at the IARS meeting (abstract S-319). A team from the University of Vermont found no evidence of learning difficulties or academic performance in 265 girls and boys in that state who had received SA for hernia repair, circumcision and other surgeries as infants (Table 2).

Table 2. Students Scoring Below the Fifth Percentile on Vermont Standardized Test

Exposed To Spinal Anesthesia

Not Exposed To Spinal Anesthesia

P Value

Math

7% (18/257)

4.8% (37/771)

0.17

Reading

7.3% (18/246)

6.1% (46/738)

0.55

“This first examination of cognitive outcome after infant SA supports the long-term safety of infant SA and implies that cognitive dysfunction seen after exposure to [general anesthesia] in previous studies may be related to effects from anesthesia and not demographics of the patient population,” they wrote.

http://www.anesthesiologynews.com/ViewArticle.aspx?d=PRN&d_id=21&i=December+2013&i_id=1020&a_id=24535&tab=MostRead