Intranasal Pediatric Sedation

Young children undergoing trans-thoracic echocardiography were sedated with intranasal Dexmedetomidine 2mcg/kg plus Ketamine 1mg/kg.  Sedation was successful in 96%, onset being about 16 minutes. Cyanotic heart disease, history of sedation failure, history of congenital heart disease surgery, and fever were independent risk factors for sedation failure. There were no serious adverse cardiorespiratory side effects.

This non-opioid combination was found to be effective with an acceptable safety profile.

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Diastolic Dysfunction and Adverse Cardiac Outcomes

This study focussed on isolated diastolic dysfunction (where Ejection Fraction > 50%). Less extensively studied than systolic dysfunction, diastolic dysfunction is associated with age, ischemia, hypertension and diabetes. These authors found that in patients with isolated diastolic dysfunction undergoing noncardiac surgery, 10.0% develop major adverse cardiovascular events (MACEs) during hospital stay after surgery; grade 3 diastolic dysfunction is associated with greater risk of MACEs.

It is unsurprising that severe grade 3 diastolic dysfunction is a higher risk, although this was a retrospective study and most patients had echocardiography due to an already higher risk status because of age and cardiovascular disease.

Other higher risk factors were also extracted from the study: age ≥70 years, body mass index <18.5 kg/m2, hypertension, coronary heart disease, arrhythmia, renal insufficiency, regular glucocorticoid therapy, symptomatic diastolic dysfunction, ASA classification grades III and IV, intraoperative use of vasopressors or antihypertensives, intraoperative fluid infusion rate ≥9.0 mL/kg/h, cancer surgery, duration of surgery ≥120 minutes, and medium- and high-grade complexity of surgery. BMI > 30 was interestingly associated with a lower risk.

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Propofol or Dexmedetomidine in Septic Shock

This study in septic shock patients addressed the common conundrum of Propofol-exacerbated hypotension and increased vasopressor requirement. They found that for a comparable level of sedation, switching from propofol to Dexmedetomidine resulted in a reduction of catecholamine requirements in septic shock patients. Dose ranges were about Propofol 2.5mg/kg/hour and Dexmedetomidine 0.7mcg/kg/hour.

This supports considering Dexmedetomidine for sedation, along with its generally positive reported effects on mitigating ICU delirium.

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Emergency Cricothyrotomy Incision

A previous Difficult Airway Society video demonstrates two cricothyrotomy techniques. In a thin subject with easily palpable landmarks, a single transverse incision all the way from skin to trachea, or the more commonly recommended vertical incision through skin first and then transverse cricothyrotomy ( link ).

This current study used ultrasound to establish some guidelines for vertical incision length and concluded:

“An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length”.

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Medical & Health News Weekly

Marine omega fatty acids don’t prevent cardiovascular events or cancer  link

Vitamin D supplementation doesn’t prevent cardiovascular disease or cancer  link

(But just to confuse the issue, some headlines putting a positive spin using less significant secondary outcomes  on Vit D and Fish oils!)

Cholesterol 2018 guidelines made simple (!)  link

Juul to stop selling most flavoured e-cigarettes link

e-cigarette use is epidemic in US high and middle schoolers – 3.6 Million of them! Experts demand stronger action from FDA  link

Intraaortic Balloon Pump has no effect on mortality in a six year follow up in myocardial infarction with cardiogenic shock  link

US recommendations for screening all over age 18 for unhealthy alcohol use, including pregnant, and offer brief behavioural counselling  link

FDA warns on intrathecal (spinal) implanted pain pumps prone to pump failures, unapproved drugs or dosing errors  link

SGLT2 Inhibitors in diabetes appear to have beneficial effects on cardiac failure hospitalizations and progression of renal disease link

 

Cannabinoids for Pain

The British Pain Society adds a rational voice to the debate and hype re cannabis and cannabinoids for pain. It confirms what studies and meta-analyses have generally found, that the evidence base for effectiveness is weak. Concerns are expressed for potential side effects especially in terms of misuse, and effects on cognition and mental health (experts have consistently warned on the dangers in teenagers and use during pregnancy).

The Society feels that there is no evidence to support routine use in pain management but acknowledges their use when other modalities fail, and provides strict advice on monitoring and supporting such patients, with a plan to withdraw them when shown ineffective.

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Safe Use Of High-Flow Nasal Oxygen (HFNO)

The Anesthesia Patient Safety Foundation provide an excellent overview of the popular and expanding use of High Flow Nasal Oxygen (HFNO), devices which are in many cases supplanting BIPAP, and  used to provide apneic ventilation during intubation, as well as post extubation and weaning from ventilation. This review also adds some caution, in particular the danger of fire, and contraindications.

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Post-Dural Puncture Headache

A small study based on chart reviews limits the findings of this study which should be tested in future controlled studies. Nonetheless an interesting approach to postdural puncture headache was performed in the form of a topical sphenopalatine ganglion block and compared to the standard epidural blood patch. This ganglion block is being tested for migraine and other headaches but remains investigational.  (These topical blocks are usually described as simply placing local anesthetic soaked swabs along the floor of the nose until reaching and stopping at the nasopharynx and left there for 10mins or so, more recently with syringes attached to nasal catheter).

These authors found a faster headache resolution at 30 and 60 minutes with sphenopalatine block.

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Graduated Compression Stockings and DVT

The Cochrane group weigh in on the common thromboembolism deterrent (TED), or graduated compression  stockings (GCS).

The evidence is supportive in surgical patients, not so clear in the medical setting.

“There is high‐quality evidence that GCS are effective in reducing the risk of DVT in hospitalised patients who have undergone general and orthopaedic surgery, with or without other methods of background thromboprophylaxis, where clinically appropriate. There is moderate‐quality evidence that GCS probably reduce the risk of proximal DVT, and low‐quality evidence that GCS may reduce the risk of PE. However, there remains a paucity of evidence to assess the effectiveness of GCS in diminishing the risk of DVT in medical patients”.

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