Sore throat after surgery prevented by throat lozenges?

Sore throat after anesthesia and surgery is quite common – more than 1 in 10 patients who have outpatient (day) surgery complain of this. Along with the sore throat, some patients have cough, hoarseness and pain with swallowing (dysphagia).

Strepsils are often advised for the treatment of sore throat, but I have not been aware of their use for prevention. My mother always gave us Strepsils to soothe a sore throat which I believed to be a classic example of the placebo effect (tablet + a mother’s love is powerful therapy). Plus they taste nice.

In recent research from Iran, patients were given lemon flavored Strepsil(R) tablets, or identically flavored placebo tablets, about 45 minutes before anesthesia. Surprisingly,  the patients who got Strepsils had only about one third (13.7%) the incidence of sore throat compared with the placebo tablets (33.3%) when assessed 20 minutes after surgery. The difference was less marked 24 hours after surgery but still significant.

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Chronic Pain after Breast Surgery is Very Common

Professor Henry Kehlet is a Danish surgeon and an innovative researcher. He has done pioneering work investigating chronic (long term) pain after surgery. It turns out that many major surgical procedures cause pain that is long-lived, that is, persists beyond 4- 6 weeks or so. This phenomenon is mostly ignored in pre-surgery discussions between surgeons and their patients and can significantly decrease quality of life after otherwise successful surgical procedures.

A November 11 study in JAMA by Kehlet and his colleagues has found that nearly half of all women treated for breast cancer have pain 1 to 3 years afterwards and in half of these women the pain is moderate or severe. The results were based on a nationwide survey in Denmark that achieved an amazing 87% response rate.

Surgery and Stents

Stents are the ingenious hi-tech devices implanted in blocked coronary arteries by cardiologists, our high priests of interventional medicine. In the last 3-5 years we’ve learned unfortunately that coronary stents are not the panacea once hoped for. A major problem with stents is that they tend to become blocked off themselves unless anti-platelet medication, such as Plavix, is taken, for months or even years.

One of the main purposes of pre-surgery evaluation is to find out whether a patient has coronary artery disease and is therefore at risk for having a heart attack or other heart complication during or after surgery. We used to assume that  offering these patients stents (‘re-vascularisation’) would protect them from these kinds of heart problems.

In fact, studies have shown that patients who’ve been very recently ‘stented’ often have worse outcomes. For major surgery, anti-platelet drugs are usually stopped, in order to prevent bleeding. Unfortunately stopping these medications, combined with the complex effects of surgery on blood clotting, leads to a much greater chance that the stent, and therefore the artery, will block off, thereby causing the cardiac complication we were trying at all costs to avoid.

Guidelines from the American College of Cardiology, the American Heart Association, and the American Society of Anesthesiologists, now recommend postponing major elective surgery in which there is significant risk of bleeding, in patients with new coronary stents.

If you have a bare-metal stent the minimum recommended wait is 4-6 weeks. If you have a drug-eluting stent the wait is 12 months after implantation.

Decision-making (e.g. when to have the surgery, when to stop or continue medications) can be quite complex in this situation. Very often, surgery cannot be postponed, and the risks have to be carefully weighed to make a good choice.

What You Should Do

Make sure your anesthesiologist and your surgeon know that you have a coronary stent, when it was put in, what type it is, and what medications you are taking.

Assessing risks and benefits, to guide decision-making about going forward (or postponing) surgery, and about stopping or continuing anti-platelet drugs will involve a discussion between your surgeon, your anesthesiologist, and your cardiologist. With your input of course.

Reference

Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents: A Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology: January 2009 – Volume 110 – Issue 1 – pp 22-23. Link.

The Surgical Checklist Saves Lives

The New England Journal of Medicine published a special study reporting the success of the World Health Organization’s Surgical Safety Checklist in reducing lives and preventing major complications after non-heart surgery. Eight hospitals in developed (US, Canada, New Zealand) and developing (India, Jordan, Kenya, Phillipines, Tanzania) countries were involved, and the positive results were seen in both settings.

The checklist involves steps at “sign-in” (e.g. verifying the patient’s identity, and the site of operation), immediately before cutting the skin (e.g. antibiotics given, X-rays are in the room), and just before the patients leaves the operating room (e.g. needle, sponge and instrument counts are complete).

The overall death rate decreased from 1.5 to 0.8%, and complications went down from 11 to 7%. This is really remarkable. If these results were achieved by a drug or a new surgical technique you can bet it would be patented immediately and be worth billions.

The explanation for such amazing results?  Use of a checklist initiates a change in mindset, culture, call it what you will, that facilitates open communication. The checklist also says that the surgeon is fallible, the anesthesiologist is fallible, the nurse is fallible, but that collectively we can help each other avoid mistakes by routinely and systematically discussing what needs to be done, and using a written list to help us all remember some key steps. Studies of human performance show that we make mistakes on routine tasks at least once or twice in every 100 times. That simply isn’t good enough in healthcare, as in other high risk human endeavors.

The fact that such checklists aren’t routinely used in the majority of the world’s hospitals is fairly shocking to many. And despite this result, it’ll no doubt take some time before such basic safety measures are embraced by ALL hospitals. Why?

As Rene Amalberti, a safety and performance expert has found, in studies across industries, there is always a tension between reliability/safety one the one hand, and productivity on the other. In healthcare we routinely stray into territory that increases risks to patients (and ourselves), not because we are cowboys, or cavalier, but because there are very real constraints on resources. We probably could do a perfect job, within the limits of medical science, if we all did one operation a day, but it would be very expensive, and all our other patients would miss out on their needed care.

It’s hard to argue against the checklist however because it’s simple to do, doesn’t cost money, and can be complete in one or two minutes.

My Advice

If you’re a patient, look for evidence that your chosen hospital is implementing checklists, across the board. Or choose another hospital.

Colonoscopy without sedation. Possible..but does it miss the point?

Colonoscopy, repeated at 5-10 year intervals, is recommended to detect colon cancer after age 50. As the American (and global) population ages, more colonoscopies will be performed, and more colonoscopists are needed.

One controversy is – who is qualified to perform a colonoscopy? Family physicians with special training argue that they are, and this would certainly ease the pressure on gastroenterologists (or offer a competitive threat?).

Another contentious area is – who is qualified to provide the sedation that most patients expect? Some gastroenterologists say that sedation is so safe that they can provide, or at least supervise it, while they do the colonoscopy. Anesthesiologists would argue the contrary. (Disclaimer: I am one – an anesthesiologist).

Outside the United States, colonoscopy is often done without sedation. This may even be the norm, as discussed in an American Medical News article which reports on a center in California which has been doing these on a routine basis, in volunteers, with some success (78% completed the study without drugs).

It’s clear from this article that colonoscopy without sedation is possible in America. But that is hardly a surprise. What’s missing in this analysis, and all the controversy, is outcomes. Not the number of colonoscopies completed, which is what is reported in these studies, but how many lesions were picked up (or missed) during the colonoscopy. That’s a much more difficult study to do, but isn’t finding (or ruling out) cancer the reason for undergoing this rather unpleasant test?

Intuitively, an endoscopist who does not have the additional responsibility of sedation, or the time pressure of completing the study as quickly as possible in an unsedated patient, has better conditions to fulfill his primary role – to find cancerous or pre-cancerous lesions in the colon and rectum. But that’s just my suspicion – let’s hope the outcome studies get done.

Brainwave synchronization reduces need for anesthesia?

In a study presented at the 2008 annual conference of the American Society of Anesthesiologists, investigators applied “hemispheric-synchronised” sounds (Hemi-Sync) to 60 patients undergoing outpatient surgery. Sounds are played through headphones and, according to the product website, ensure the “left and right hemispheres are working together in a state of coherence”. Patients used the Hemi-Sync before and during surgery, while control patients listened to music or a blank cassette.

A similar study (76 patients) was done in 1999, but in the current investigation the level of anesthesia was controlled using a brainwave monitor called the Bispectral Index.

Hemi-Sync is one of several gizmos marketed to harness human brain waves. Purported benefits include financial success, improved sleep, weight loss, spiritual growth and more.

Do they help with anesthesia and recovery from surgery?

Questioning the need for blood transfusion

Have Jehovah’s witnesses been right all along? About blood transfusion, that is.

There is increasing evidence that a “liberal” approach to the transfusion of blood is the wrong approach. For instance, transfusion seems to increase the risk of infection. But it’s not the kind of infection that most people worry about, dread viruses like hepatitis or HIV. Rather, transfusion inhibits the immune system and leads to higher rates of so-called nosocomial, or hospital-acquired, bacterial infection (bloodstream infections, pneumonia, urinary infection).

There’s even a seldom appreciated increased risk of acquiring cancer over subsequent years.

A new retrospective study has shown that banked blood stored for more than 4 weeks is associated with more infection in the patients who receive it. Blood is scarce and expensive, and most blood banks store it for up to 42 days before administration.

What’s the right perspective? Except for certain religious groups blood transfusion isn’t evil and, as always, an appreciation of risks and benefits is necessary. Blood can be life-saving. And patients with severe heart or lung disease, for example, do poorly without transfusion in circumstances that healthier people easily tolerate.

What you can do

1. If you are in a position to do so – e.g. before elective joint surgery – it’s wise to ask a few questions of your doctor about blood transfusion. The right questions, plus a lot useful information, is contained in a nice booklet (PDF) put out by the Society for Advancement of Blood Management.
2. If you are about to undergo surgery in which significant blood loss is expected, your hemoglobin level should be checked ahead of time. A low level (anemia) detected only in hospital could lead to an unnecessary blood transfusion, avoidable through the administration of iron, by mouth, or an injection of erythropoietin, a drug that stimulates the body to produce red blood cells.

Acupuncture or chili powder for pain after surgery

Devotees of oriental medicine will not be surprised by the finding, in the British Journal of Anaesthesia, that acupuncture reduces pain after surgery. More unexpected is that chili powder applied to the skin below the knee can produce the same effect!

In this meta-analysis fifteen studies were analysed – over 1100 patients. In each study, acupuncture was compared with control “sham” acupuncture (acupuncture applied to non-acupuncture points).

• Acupuncture patients needed less opioid (morphine-like) pain treatment at 8, 24 and 72 hours after surgery
• Postoperative pain was also significantly less in the acupuncture group at 8 and 72 h compared with the control group.
• The acupuncture treatment group had a lower incidence of opioid-related side-effects such as nausea, dizziness, sedation, pruritus (itching), and urinary retention (inability to urinate).

The authors conclude that “perioperative acupuncture may be a useful adjunct for acute postoperative pain management”. I was intrigued, and decided to explore the methods used in one of the 15 studies in a bit more detail (Kim KS, Nam YM. The analgesic effects of capsicum plaster at the Zusanli point after abdominal hysterectomy. Anesth Analg 2006; 103: 709–13).

Does anesthesia have long term effects on a child’s brain?

Whether anesthesia, or surgery, or some combination of the two, have long-lasting effects on the brain of children is an important question which researchers are trying very hard to answer. Three new studies provide some cause for concern.

In a non-clinical, (epidemiologic), study from Columbia University the authors used databases to review cases in which children had hernia surgery in the first four years of life. They found that these children, compared with a control group, had almost twice as much risk of subsequently developing behavioral or developmental disorders.

In a second study, from the Mayo Clinic, the risk of learning disabilities in children after a single anesthetic was not different from a control group but the risk did increase after two or three anesthetics and in the cases where the duration of the anesthetic was longer than 2 hours.

Finally, a Dutch study of children who had urologic surgery. “Neurocognitive” development was evaluated by means of a questionnaire completed by parents. Children who had their procedures before the age of two years had lower scores but the study wasn’t large enough to say with any certainty that this age cut-off is important.

Blood clots after surgery – call to action

Deep vein thrombosis (DVT) and pulmonary embolism (PE) – “blood clots” – kill about 100,000 Americans each year. Many blood clots occur after routine elective surgery – especially spine surgery and major surgery on the hip or knee.

An excellent consumer guide to the risks, prevention and treatment of blood clots can be found here.

The Office of the Surgeon General in the US recently called for action to address this major public health problem. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism documents the problems DVT and PE pose, as well as strategies to reduce the risk of developing the conditions. Clearly we need to improve public knowledge about risk factors, triggering events, and symptoms of the disease, which is often silent.

Before any surgical procedure, particularly those requiring more than a day or so in hospital, you should be evaluated for any risk factors for a blood clot. People at risk need preventive measures, which can include anticoagulants, like heparin, special stockings, or the use of automated calf compression devices.

Rapid mobilisation – i.e. getting out of bed – is one of the best ways to avoid blood clots and is one of the reasons why patients having outpatient or day surgery very seldom need specific preventive treatments.