Wessex Intensive Care Society (WICS)

Hot topics

ESA 2013: Hot Topics: Last Year's Top Publications in Anaesthesia

Presented at ESA 2013 by Benedikt Pannen
Past Chairman of the ESA Scientific Committee, and Professor and Chair of the Department of Anaesthesiology at the University Hospital Düsseldorf, Germany

Summarised by Dr Adrian Wong

1. Perioperative mortality - how are we doing?
Mortality after Surgery in Europe: A 7 day cohort study
Lancet, September 22, 2012; 380: 1059-1065.
R. Pearse et al. for the EuSOS group.


Previous work on estimating postoperative mortality in Europe showed an overall mortality rate of 1.8% (Anesthesiology 2010; 112(5): 1105-1115). This obviously varied depending on the type of surgery.

I think most of us would have read this observational study that looked at patients undergoing assessed non-cardiac surgery patients between the 4
th to 11th of April, 2011. It covered a total of 498 Hospitals in 28 European nations.

Overall, the death rate in hospital after surgery was found to be 4%, higher than many previous estimates and with a substantial degree of variation between countries. Scandinavian countries had better mortality rate compared to the Eastern European ones (UK mortality was referenced). There were obvious questions and rebuttals over the quality of data collected.

5% of patients underwent a planned admission to critical care but 73% of patients who died were not admitted to critical care at any stage after surgery, and of patients who died after admission to critical care, 43% did so after the initial episode was complete and the patients had already been discharged to a standard ward.

Discussion points
  • Mortality rate for patients undergoing non-cardiac surgery is higher than anticipated.
  • Variation in mortality rates suggest need for national and international strategies to improve care.
  • Systematic failure in the process of allocation of critical care resources.

2. Myocardial protection - do volatile anaesthetics do the job?
Randomised Comparison of Sevoflurane versus Propofol to reduce Perioperative Myocardial Ischaemia in Patients undergoing Non-Cardiac Surgery
Circulation, December 4, 2012; 126: 2696-270
G. A. L. Lurati Buse et al.

This study found no significant difference between propofol and sevoflurane in reducing myocardial ischaemia in patients undergoing non-cardiac surgery.

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A multinational study of 8351 patients undergoing non-cardiac surgery by Devereaux et al (Ann Intern Med 2011; 154: 523-528) showed that 5% of patients had a perioperative MI, and the 30-day mortality rate was higher for patients who had an MI (12%) than for those who did not (2%). The idea of preconditioning, either ischaemic or pharmacologically, is not a new one (Anaes 1976; 45: 287). Halothane decreases ST elevation in experimental dog models). Despite the paucity of robust studies, the American College of Cardiology Foundation/American Heart Association called for the use of volatile anaesthetics in their 2011 guidelines.

Volatile anesthetic-based regimens can be useful in facilitating early extubation and reducing patient recall (Myles et al., 2003; Dowd et al., 1998; Groesdonk, et al., 2010; Cheng et al., "Early," 1996). (Level of Evidence: A)

European guidelines do not. Note that the references provided by the ACCF/AHA are at least 3 years old.

More recent studies discussed by Prof Pannen –
  • Circulation 2012;126:2696-2704. RCT multicentre. Etomidate induction. Maintenance with either sevoflurane or propofol. Primary end point MI measured at day 1 and 2 postop. No difference between propofol and sevoflurane groups. No significance difference in multiple secondary end points.
  • J Cardiothorac Vasc Ana 2011;25:902-907. TIVA vs sevoflurane - no difference. Limitations - clearly not blinded. Lack of standardisation e.g. Opioid doses. Other drugs which are protective e.g. Beta blockers, statins, are exerting maximum protective effect.

Sevoflurane does not reduce the incidence of myocardial ischemia in high-risk patients undergoing non-cardiac surgery compared with propofol.

3. Delirium and POCD. Can we further minimise the risk?

ISPOCD1 (International Study on Post-Operative Cognitive Dysfunction) study (Lancet 1998; 351: 857-861) showed an incidence of POCD of 25.8% at 1 week and 9.9% at 3 months. Post-operative delirium has a long-term effect on cognitive function (NEJM 2012; 367: 30-39).

Bis-guided Anesthesia decreases Postoperative Delirium and Cognitive Decline J Neurosurg Anesthesiol, January 2013; 25: 33-42
M.T. Chan et al. for the CODA Trial Group

RCT in Hong Kong. BIS (40-60) guided vs routine care. Primary outcome POCD at 3 months. BIS guided group had mean BIS 53 compared to 36 in control. BIS group had less volatile or propofol administered. BIS group had lower incidence of delirium and POCD. For every 1000 patients, BIS-guided anaesthesia prevented 83 patients from suffering delirium (number needed to treat = 12).

Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction
Br J Anaesth, March 28, 2013 [Epub ahead of print]
F. M. Radtke et al.

Bis guided vs routine care. Mean BIS was similar in both groups but BIS guided group spent shorter time with lower BIS less than 40. Lower incidence of delirium in BIS group.


The Triple Low (MAP, BIS and MAC) has been shown to be associated with increased mortality risk (
Anaes 2012; 116: 1195-1203).

BIS reduces risk of delirium in elderly patients undergoing non-cardiac surgery NNT 12.

Adapted from the ESA 2013 Summary Newsletter