Case for tomorrow

[BLADEMDA]

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There's an ongoing study looking at the effect of beach chair vs lateral position on cerebral autoregulation and cardiac output. It'll help answer many of our questions

http://clinicaltrials.gov/ct2/show/NCT01225185?term=hogue&rank=6

Johns Hopkins Med Ctr and they ae using a biomarker. Still, the results will be interesting but not definitive.

The co-sponsor is the APSF the same group which recommends a higher mean BP in the beach chair position and the same group which has brought all this to our attention.

The study should be completed by now (they used a biomark and cerebral oximetry) so I expect the published results in 2013.

The specific aims of this study are:

• To compare the average cerebral oximetry index and the percentage of time with abnormal COx between subjects in the head up or supine position during surgery under general anesthesia.
• To compare the range of arterial blood pressure required for a normal cerebral oximetry index between subjects anesthetized in the head up or supine position.
• To assess the association between impaired cerebral blood flow autoregulation and postoperative neurocognitive decline 1 month after surgery and perioperative elevation of serum glial fibrillary acid protein.

Monitoring autoregulation non-invasively with COx has the potential to improve patient safety by delineating individualized limits of safe ABP for patients at risk of neurologic injury.

 

[cchoukal]

Blade's posts make several good points, the most compelling of which is that the truth isn't always what's relevant on the witness stand. The APSF is THE safety arm of the field, so what they say carries weight, but my experience has been that their pronouncements are often based on little actual data. My hospital was asked to consider sidestream capnography (essentially nasal cannula EtCO2) for floor patients on PCAs. The idea was to prevent respiratory events from opiate use. The idea has tremendous face validity, but is expensive, creates the potential for unlimited false alarms, and is completely unproven. The manufacturers often cited APSF recommendations, but when you go and search for the genesis of those recommendations, you find that they come from a survey conducted at one meeting where people (half of whom were 'industry') answered questions like "do you think capnography could save lives?"

And in this example, Blade cites registry data suggesting the risk of stroke is no higher, and yet APSF can still recommend whatever they want, and if you have a bad outcome, is the jury going to appreciate the subtleties of the "level of evidence" used in the APSF recs?

This type of thing happens locally as well. I'm sure many of your hospitals are creating "pathways of care," or clinical protocols. I wonder what happens when you break protocol (for a good reason or not) and a bad outcome occurs. I wonder who's got your back, or who will listen and understand the subtlety behind your decision to deviate. I wonder how solid are the data behind all these protocols and recommendations.