2 Minute Medicine Rewind November 30, 2020

Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study

1. Among patients undergoing lower limb revascularization, the use of neuraxial compared with general anesthesia was associated with decreased 30-day all-cause mortality.

Evidence Rating Level: 2 (Good)

Although endovascular interventions are increasingly common for the surgical management of peripheral artery disease, lower limb revascularization surgeries like endarterectomy and arterial bypass are still frequently performed. This comparative effectiveness study evaluated whether use of neuraxial anesthesia or general anesthesia for patients undergoing lower limb revascularization would be associated with improved clinical outcomes. Patients were recruited from multiple centers across Ontario, Canada. The primary outcome was 30-day all-cause mortality; secondary outcomes included in-hospital cardiopulmonary and renal complications and postoperative length of hospital stay, among others. 20,988 patients were included in the analysis, of whom 6,453 received neuraxial anesthesia (mean [SD] age = 70.6 [10.7] years, 33.0% female) and 14,535 received general anesthesia (mean [SD] age = 67.6 [12.7] years, 32.8% female). Of note, the use of neuraxial anesthesia declined by 17% over the course of the study period. Death within 30 days of surgery occurred in 204 (3.2%) patients who received neuraxial anesthesia and in 646 (4.4%) who received general anesthesia; after multivariable, multilevel analysis, the risk was found to be significantly lower in patients receiving neuraxial anesthesia (aOR 0.68, 95% CI 0.57 to 0.83, p < 0.001). This corresponds to a number needed to treat of 139 to prevent one death at 30 days by favoring the use of neuraxial anesthesia. Moreover, the use of neuraxial anesthesia was associated with a decreased risk of in-hospital cardiopulmonary or renal complications (aOR 0.73, 95% CI 0.63 to 0.85, p < 0.001) as well as a reduced length of hospital stay (aOR -0.5 days, 95% CI -0.3 to -0.6 days, p < 0.001). In all, this study suggests that using neuraxial anesthesia over general anesthesia for lower limb revascularization is associated with a decreased risk of postoperative morbidity and mortality. Prospective studies, though, are needed to clarify these findings.


Effect of continued perioperative anticoagulant therapy on bleeding outcomes following robot-assisted radical prostatectomy

1. Patients continuing perioperative anticoagulation when undergoing robot-assisted radical prostatectomy did not experience an increased incidence of high-grade bleeding.

Evidence Level Rating: 2 (Good)

Robot-assisted radical prostatectomy (RARP) is the standard of care for surgical management of localized prostate cancer. As RARP is classified as a hemorrhagic procedure, patients on anticoagulation who have a high risk of thromboembolic complications are generally asked to stop anticoagulation and/or receive bridging therapy with heparin derivatives. The purpose of this retrospective study was to assess the impact of continuing perioperative anticoagulation administration in patients undergoing RARP. The primary outcome was the incidence of 90-day bleeding complications requiring transfusion, additional intervention, or readmission. 606 patients were included for analysis and followed until 90 days postoperatively. Among them, 105 continued anticoagulation, including 31 patients taking warfarin or direct oral anticoagulants (anticoagulation cohort), 13 patients taking clopidogrel or prasugrel (thienopyridine cohort), and 61 patients taking aspirin (aspirin cohort). It was found that the incidence of bleeding complications was not significantly different between the anticoagulation cohort and the thienopyridine, aspirin, and control cohorts (3% vs. 8% [p = 0.51]; 0% [p = 0.34]; and 0.4% [p = 0.17], respectively). Importantly, no patients in any cohort required secondary interventions to control postoperative bleeding. Furthermore, there was no significant difference between the anticoagulation cohort and the thienopyridine, aspirin, and control cohorts with regards to the incidence of thromboembolic complications (3% vs. 0% [p = 0.70]; 2% [p = 0.56]; and 0.2% [p = 0.11], respectively). Overall, this study suggests that continuing perioperative use of anticoagulation in patients undergoing RARP is safe and does not increase the risk of high-grade bleeding complications. Further verification of these findings with randomized studies, however, is warranted.


Spironolactone Use and Improved Outcomes in Patients With Heart Failure With Preserved Ejection Fraction With Resistant Hypertension

1. Among patients with HFpEF and resistant hypertension, administration of spironolactone was associated with a reduced risk of composite cardiovascular events, all-cause mortality, and hospitalization for heart failure.

Evidence Level Rating: 2 (Good)

Heart failure with preserved ejection fraction (HFpEF) and resistant hypertension, a salt-retaining condition secondary to inappropriate aldosterone secretion, commonly co-occur, complicating medical management. This study represents a secondary analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study, a randomized study from 2014 demonstrating that spironolactone, an aldosterone antagonist commonly used in the management of heart failure, does not have a mortality benefit for patients with HFpEF. The aim of this current analysis was to assess whether spironolactone use leads to improved outcomes among patients specifically with HFpEF and concomitant resistant hypertension. The primary outcome was a composite of cardiovascular death, aborted cardiac arrest, and hospitalization for heart failure. From the original TOPCAT cohort, 3,146 patients had HFpEF and hypertension, of whom 1,004 had HFpEF and resistant hypertension (median [IQR] age = 69 [61-76] years, 51.9% female). The risk of the primary outcome among patients with HFpEF and resistant hypertension was significantly lower in the spironolactone group than in the placebo group (HR 0.70, 95% CI 0.53 to 0.91, p = 0.009). However, the risk of the primary outcome among patients with HFpEF without resistant hypertension was not significantly different between the spironolactone and control groups (HR 1.00, 95% CI 0.83 to 1.20, p = 0.97). With regards to specific outcomes, the risk of all-cause mortality and hospitalization for heart failure was significantly lower in the spironolactone group for patients with HFpEF and resistant hypertension, but not for those without resistant hypertension. These data suggest that spironolactone may be an appropriate add-on medication for patients with HFpEF and resistant hypertension already taking ACEIs/ARBs, CCBs, and diuretics.


Effect of Ezogabine on Cortical and Spinal Motor Neuron Excitability in Amyotrophic Lateral Sclerosis

1. Dose-dependent ezogabine was shown to decrease motor neuron excitability, a marker of disease progression, in patients with amyotrophic lateral sclerosis.

Evidence Level Rating: 1 (Excellent)

Associated with the progressive loss of cortical and spinal motor neurons, amyotrophic lateral sclerosis (ALS) portends a poor prognosis. Studies have shown that greater motor neuron excitability is prognostic of disease progression. This phase 2, randomized study investigated whether ezogabine, an antieplietptic medication that activates KCNQ potassium channels, decreases cortical and motor neuron excitability in patients with ALS. 23 patients were randomized to receive 600 mg/day of ezogabine (mean [SD] age = 58.8 [9.5] years, 17.4% female), 19 to receive 900 mg/day of ezogabine (mean [SD] age = 58.9 [9.1] years, 31.6% female), and 23 to receive a placebo (mean [SD] age = 57.4 [8.0] years, 43.5% female). The primary outcome was change in short-interval intracortical inhibition (SICI), a decrease of which is seen in early ALS and is associated with cortical hyperexcitability. SICI-1, a log transformation differing from SICI only in sign, was used in analysis so that greater inhibition resulted in increased amplitude. A dose-dependent increase in SICI as measured by SICI-1, the primary outcome, was observed across the treatment groups compared with the placebo group (mean ratio 600 mg/day ezogabine group: 1.15, 95% CI 0.87 to 1.52, p = 0.31; 900 mg/day ezogabine group: 1.53, 95% CI 1.12 to 2.09, p = 0.009). Furthermore, ezogabine exhibited dose-dependent changes in specific parameters related to axonal excitability, including a decrease in strength-duration time constant (SDTC) and an increase in rheobase, both markers of membrane excitability, threshold electrotonus, and recovery cycles. In all, this study demonstrated that ezogabine decreased motor neuron excitability among patients with ALS. Further studies, though, are needed to assess whether it has sustained effects on excitability and can slow disease progression.


Comparison of laparoscopic percutaneous extraperitoneal closure and laparoscopic intracorporeal suture in pediatric hernia repair

1. Among children requiring inguinal hernia repair, those receiving laparoscopic percutaneous extraperitoneal closure had a faster time to recovery, experienced fewer complications, and had enhanced cosmetic results.

Evidence Level Rating: 2 (Good)

Surgical repair of inguinal hernias among children is very common, and high-quality evidence suggests that laparoscopic minimally invasive surgery (MIS) is superior to open surgery. This retrospective study compared two types of MIS inguinal hernia repair – intracorporeal and extracorporeal – to determine which is superior. 474 patients were included, 214 of whom underwent laparoscopic intracorporeal suture (LIS) (mean [SD] age = 53.0 [31.3] months) and 260 laparoscopic percutaneous extraperitoneal closure (LPEC) (mean [SD] age = 54.9 [36.6] months). Compared with the LIS group, average surgery time in the LPEC group was significantly lower for both unilateral (15.76±5.35 min vs. 19±5.71 min, p = 0.04) and bilateral (21.56±5.7 min vs. 26.38±6.94 min, p = 0.01) repairs. Both groups had the same number of patients who required analgesics after surgery. However, the LPEC group required less time to fully recover than the LIS group (3.92±0.832 days vs. 4.27±0.895 days, p = 0.017). Furthermore, there were more surgical site infections in the LIS group as well as more recurrent hernias, but neither of these differences reached statistical significance. With regards to scar visibility, the mean scar rating using a five-point scale was higher in the LPEC group compared with the LIS group (4.61±0.095 vs. 4.07±0.26, p = 0.02), indicating that the post-operative scar was less visible. Additionally, mean rating for cosmetic satisfaction was numerically, but not significantly, higher in the LPEC group. In all, this study demonstrated the efficacy of laparoscopic hernia repair using an extracorporeal approach with reduced operative time, more rapid recovery, and improved cosmetic results.

Image: PD

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