Sore throat after surgery prevented by throat lozenges?

October 7, 2010

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.

Read the rest of this entry »


Chronic Pain after Breast Surgery is Very Common

November 18, 2009

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.

Read the rest of this entry »

Surgery and Stents

March 1, 2009

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.


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

January 18, 2009

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.

Brainwave synchronization reduces need for anesthesia?

November 2, 2008

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? Read the rest of this entry »

Acupuncture or chili powder for pain after surgery

October 10, 2008

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). Read the rest of this entry »

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

September 28, 2008

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. Read the rest of this entry »

Statins – good for the heart, bad for the brain?

September 23, 2008

A study in the Canadian Medical Journal, accompanied by a commentary, looks at statins and postoperative delirium.

This condition (“an acute change in mental status that is worrisome to patients and families”) is a big concern for many elderly patients (and their families) having major surgery. Unfortunately we don’t yet know enough about the predisposing factors and direct causes to do very much about preventing postoperative delirium, apart from avoiding some things which are obviously bad for all patients (e.g. low blood pressure, inadequate oxygen, etc). Delirium increases the average length of a hospital stay by about a week, is associated with a variety of complications and increased costs, and may even be linked to permanent brain deficits.

This study suggests that statin drugs predispose to postoperative delirium. Is the conclusion correct? Should it change medical practice, which currently strongly favors the continuation of statins after surgery because of their protective effect on the heart? Read the rest of this entry »

Statins – not just for cholesterol

September 10, 2008

Statins – the drugs like Lipitor, Crestor, Zocor, Lescol and others – do more than reduce your cholesterol. Several studies have shown that these drugs protect people with heart disease having major non-heart surgery. The beneficial effect seems to come from anti-inflammation properties common to all statins.

The latest, and perhaps strongest piece of evidence so far comes from a new study in the Netherlands in which patients having vascular (blood vessel) surgery – known to have the highest risk of heart attack after surgery – were given a long-acting statin – fluvastatin – and continued on it after leaving the hospital. The statin cut the rate of heart attack and of myocardial ischemia (angina, or where the heart muscle doesn’t get enough blood supply) by about 50%. Read the rest of this entry »

Information overload during the pre-anesthesia interview

September 8, 2008

How much can you learn all in one go? Cognitive science has established that on average we can hold only seven or so “chunks” of new information.

In this Sept 2008 study in Anesthesia & Analgesia, patients interviewed in a pre-anesthesia clinic in Boston were heavily overloaded with information by nurses and doctors. Audio recordings showed that nurse practitioners attempted to transmit on average more than 110 pieces of information during the interview. The doctors came in with roughly 50 apiece. Read the rest of this entry »