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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Bulletin Brief

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

February 8, 2022

From JACS

The Challenging, Ethical Intersection of Planned Surgical Procedures and DNAR Order

John PR, Tisherman SA, Truog RD. Do not attempt resuscitation in the operating room: A misconstrued paradox? J Am Coll Surg;2022, in press.

Angelos, P. The challenge of DNR orders in the operating room. J Am Coll Surg; 2022, in press.

In this article, the authors discussed the various challenges in determining the proper course and appropriate patient communication when a surgical procedure is planned for patients with "do not attempt resuscitation" (DNAR) orders. They noted that various professional organizations have published guidelines that have consistently endorsed "required reconsideration" of the order. According to data cited in the article, a significant proportion of clinicians who are questioned on this subject support suspension of the order during the operation.

The article stressed that presence of a DNAR order does not mean that intraoperative clinical deterioration should go untreated. Hemodynamic deterioration resulting from hemorrhage, non-life-threatening cardiac arrythmias, and anesthesia-related abnormalities should not be considered equivalent to a cardiac arrest event. Preoperative discussions involving the operating surgeon and anesthesiologist are strongly recommended. These conversations should discuss differences in management of events that can usually be remedied compared with a cardiac arrest event. The authors recommended presenting the patient with options for management of intraoperative complications based on three levels of care:

  • Level One – measures usually employed to manage problems related to anesthetic agents
  • Level Two – measures employed to manage hemodynamic instability
  • Level Three – need for cardiopulmonary resuscitation (chest compressions, defibrillation, extracorporeal cardiovascular support)

The authors supported suspension of the DNAR order for levels one and two based on available data. Discussion of the best action for level three should be an area of emphasis in the preoperative patient conversation, with suspension of the DNAR order based on the wishes of the patient and/or the surrogate caregiver.

In the editorial comment that accompanies the article, Peter Angelos, MD, FACS, provided a useful perspective on the history of "required reconsideration" and emphasized the critical importance of the preoperative discussion of options that should involve the surgeon, anesthesiologist, patient, and surrogate caregiver(s).

Patient-Reported Pain Outcome after Targeted Muscle Reinnervation at Time of Major Limb Amputation 

O'Brien A, West JM, Gokun Y, et al: Longitudinal durability of patient reported pain outcomes after targeted muscle reinnervation at the time of major limb amputation. J Am Coll Surg; 2022, in press.

Saberski ER, Potter BK: Targeted muscle reinnervation: an enduring solution to unendurable pain after amputation? J Am Coll Surg; 2022, in press.

Post-amputation pain (residual limb pain, phantom limb pain) affects 50% to 90% of amputees. Targeted muscle reinnervation (TMR)—rerouting of divided nerves into redundant motor end targets in residual muscle—is a recently developed approach for reducing the burden of post-amputation pain. The article reported data from a prospective cohort study of 83 patients who had TMR; follow-up data were obtained for at least 18 months postoperatively, and pain was rated according to accepted scales. Complete data with an average follow up of 2.4 years were available for 23 patients, and partial data were available for the remainder. Compared with patients who did not have TMR, the study patients showed consistently lower pain scores and significantly improved quality of life. The authors concluded that TMR was an effective means of preventing post-amputation pain.

In the editorial that accompanied the article, Saberski and Potter stressed the importance of patient selection because use of TMR in patients who have a significant risk of postoperative pain would be preferred. They also noted that expansion of training in TMR technique is important because the procedure requires the availability of a microvascular surgeon. Nonetheless, the data showed that TMR is a potentially valuable procedure and should be used consistently in patients at risk for post-amputation pain.

Other Journals

Multiprofessional Preoperative Assessment for Head and Neck Cancer Patients and Postoperative Outcomes 

Schmid M, Giger R, Nisa L, Mueller SA, Schubert M, Schubert AD. Association of Multiprofessional Preoperative Assessment and Information for Patients With Head and Neck Cancer With Postoperative Outcomes. JAMA Otolaryngol Head Neck Surg. Jan 20, 2022;doi:10.1001/jamaoto.2021.4048

This case-control study examined rates of postoperative complications, readmissions, and mortality in patients needing complex surgical care for head and neck cancer who underwent a multidisciplinary preoperative assessment, presentation of comprehensive information, and a preoperative briefing. These patients were compared with patients who had conventional preoperative preparation. The preoperative assessment team consisted of the attending surgeon and anesthesiologist, along with an advanced nurse practitioner, a psychologist, a speech therapist, outpatient clinic nurse, and a social worker. The preoperative assessment and briefing required approximately 8 hours to complete.  The study involved 161 patients; 81 patients were included in the intervention group.

The intervention group had fewer postoperative complications, shorter hospital stays, and decreased costs compared with the control group. Although data on costs of implementation of the team assessment, briefing process, and patient-reported outcomes were omitted from the study data, the noted patient and cost benefits suggested that the use of the comprehensive assessment and patient briefing has potential value for improving outcomes in patients undergoing complex surgical procedures.