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Journal Club Express - multimodal pain management Jun 15, 2018

Show notes

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.

Memtsoudis SG1, Poeran J, Zubizarreta N, Cozowicz C, Mörwald EE, Mariano ER, Mazumdar M.

BACKGROUND: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.

METHODS: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.

RESULTS: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P

CONCLUSIONS: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

DOI: 10.1097/ALN.0000000000002132

RCoA Conference Highlight: Do we still care about direct laryngoscopy? Jun 14, 2018

Show notes

The debate 'Direct laryngoscopes should be consigned to history' was hosted by The Royal College Of Anaesthetists and carried out by the two guests on this piece.

The conversation explores the fact that this skill is a key part of the job of practitioners, are we "de-skilling" the profession in an overly enthusiastic race toward new technology, or are some resisting it simply because it's not what they are used to?

This piece is taken from a longer conversation, to be found here: https://www.topmedtalk.com/rcoa-12-should-direct-laryngoscopes-be-consigned-to-the-history-books/

Where do you stand on the debate? Send us your thoughts: contact@topmedtalk.com

Presented by Joff Lacey and Monty Mythen with their two guests; Professor Tim Cook, Consultant in Anaesthesia and ICM, Royal United Hospitals, Bath and Dr William Harrop-Griffiths, St Mary's Hospital, Imperial College Healthcare NHS Trust.

ISEH Highlight: Give your patients a warm welcome. Jun 13, 2018

Show notes

The patient experience can be quite passive and, as a result, people can lose temperature quickly. The consequences can be very negative, this conversation revolves around how you can keep your patients warm.

This piece is taken from a longer conversation to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-1/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features Professor Monty Mythen and his guest Mark Harper, Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for theraputic purposes.

'Anesthesia and Analgesia' go big on POQI Jun 12, 2018

Show notes

This piece focuses on the latest print issue of 'Anesthesia and Analgesia' which is saturated with coverage of the Perioperative Quality Initiative (POQI), the most recent meeting of which was sponsored by the American Society of Enhanced Recovery (ASER).

This conversation acts as an update on where some of the latest thinking is as regards perioperative medicine. It includes a deep dive into gastrointestinal tract dysfunction and allows you to find out the best "whey" to an enhanced recovery alongside information about nutrition screening.

There's also a look at the perioperative medicine calendar, with details on how you can meet Monty and the team at one of the many events we're covering over the next few months.

Monty Mythen is interviewing Dr Tim Miller from Duke University Medical Centre.

Send us your thoughts: contact@topmedtalk

Web links:

- The ASER open source articles mentioned in the piece can be found on the POQI website.

- Also in this piece there is news about, The Morpheus Consortium, there's more information here: http://morpheusconsortium.org

- And finally, the website Dr Tim Miller mentions, is here: https://anesthesiology.duke.edu

Good noises for ultrasound. Jun 11, 2018

Show notes

Most people are familiar with ultrasound these days, next to the stethoscope and thanks largely to baby photographs, it's one of the most frequent public facing technologies in medicine.

New developments in transesophageal echocardiography have brought about huge advancements in its use as a technology; not to mention the incredible images now available from three dimensional echocardiography. As ultrasound becomes more available and more portable this conversation gives you an idea of where, when, why and how you can use this incredible tool. Is it really a piece of bedside assessment equipment which is about to become as ubiquitous as a doctor's thermometer?

It's difficult not to get excited about the ability to take a quick look at a patient's cardiac function, at the bedside, with a handheld piece of kit. Scanning a patient's abdomen, seeing how to apply appropriate measures of care rapidly on the spot, these are just some of the advantages discussed in this piece.

See more here:

Acute Care and Perioperative Ultrasound Workshop Co-sponsored by the Departments of Anesthesiology at Loma Linda and UCLA Medical Centers.

www.pocuseducation.com

Evidence-Based Perioperative Ultrasound Educational Curriculum (created as a free, open-source, platform for point of care ultrasound education)

www.foresightultrasound.com

Professor Monty Mythen is presenting, with his guest, Davinder Ramsingh MD, Director of Research and Perioperative Ultrasound at Loma Linda University Medical Center - Dept. of Anesthesiology.

An interview with Professor Monty Mythen, our Editor in Chief Jun 10, 2018

Show notes

What is TopMedTalk and how did it come about? Why is perioperative medicine such an inspiration to us? Why is our Editor in Chief such an advocate? What is the opioid crisis?

Broadcaster Nick Margerrison speaks with our Editor in Chief about TopMedTalk and perioperative medicine.

We regularly enjoy reading your feedback: contact@topmedtalk.com

RCoA Conference Highlight: It's time to get it right, first time Jun 09, 2018

Show notes

The GIRFT (Getting It Right First Time) project. The stated aim is 'to help improve the quality of care within the NHS by reducing unwarranted variations, bringing efficiencies and improving patient outcomes'. This piece gives you the detail from one of the joint clinical leads. This piece is taken from a longer piece to be found here: https://www.topmedtalk.com/rcoa-13-the-girft-getting-it-right-first-time-project/ Also, if you'd like to hear more about The GIRFT (Getting It Right First Time) project, there's another podcast where we speak about it here: https://www.topmedtalk.com/live-from-the-iseh-part-2/ Presented by Monty Mythen, Joff Lacey and Desiree Chappell with their guest Dr Michael Swart, Consultant in Anaesthesia and Critical Care Medicine at Torbay Hospital and advisor to the UK Department of Health for the Enhanced Recovery Programme.

Journal Club Express: ICU Nurse-Led Communication, shorter stay and better ratings? Jun 08, 2018

Show notes

A Randomized Trial of a Family-Support Intervention in Intensive Care Units

Douglas B. White et al. for the PARTNER Investigators

Surrogate decision makers (e.g. family and friends) for incapacitated, critically ill patients can understandably find it very difficult to make decisions related to goals of care.

Having to make such decisions can cause them psychological distress and may lead to treatment that is not exactly what the patient might have chosen if they could speak for themselves.

In this trial the investigators conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates (folks speaking for them) in five intensive care units (ICUs).

They compared what they term "a multicomponent family-support intervention delivered by the interprofessional ICU team" with usual care.

A total of 1420 patients were enrolled in the trial.

Results

The family-support intervention delivered by the interprofessional ICU team did not significantly reduce the burden of psychological symptoms for the surrogates.

However their ratings of the quality of communication and the patient- and family - centered care were better. Furthermore - the length of stay in the intensive care unit was shorter.

Compelling, in favour of this team approach, but the authors suggest we shouldn't 'dive straight in'; rather that a large replication trial may be conducted, in multiple geographic regions, to establish the findings further.

Thus recognising different health systems have potentially different attitudes and practices regarding care for patients with advanced critical illness.

We will be delving into this excellent paper at greater length in an upcoming journal club.

Link to paper:

The New England Journal of Medicine:

https://www.nejm.org/doi/full/10.1056/NEJMoa1802637

Link to the accompanying editorial by Daniela Lamas, Nurse-Led Communication in the Intensive Care Unit:

https://www.nejm.org/doi/full/10.1056/NEJMe1804576

RCoA Conference Highlight: When do you become geriatric? Jun 07, 2018

Show notes

Geriatricians naturally fit into the perioperative sphere. Shared decision making is an obvious aspect of this, as is preoperative assessment and the consideration of the risks and benefits of surgery.

Also in this piece; when do you become geriatric?

This piece is taken from a longer conversation to be found here: https://www.topmedtalk.com/rcoa-06-geriatric-care-and-the-value-of-teamwork/

Desiree Chappell and Monty Mythen interview their guest Dr Jugdeep Dhesi, Clinical Lead, POPS and Consultant Geriatrician, Guys and St Thomas' NHS Trust.

Join in the debate: contact@topmedtalk.com

RCoA Conference Highlight: Perioperative medicine for the world Jun 06, 2018

Show notes

How can perioperative medicine be part of helping less developed healthcare systems? The considerations are different but the principles remain the same. The birth of the NHS gave parity of esteem to anaesthetists, the benefits of this are felt by us all in the Western world, could it be argued that this visionary decision might actually help other healthcare systems to evolve more rapidly?

This piece is taken from a longer conversation to be found here: https://www.topmedtalk.com/rcoa-04-the-royal-college-of-anaesthetists-world-leading-healthcare/

Presented by Monty Mythen with their guests Dr Liam Brennan, President of The Royal College of Anaesthetists (RCoA) and Professor Paul Myles, Director, Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia.

Join the debate: contact@topmedtalk.com

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