Preoperative Erythropoietin And Transfusion in Surgical Patients

Erythropoietic-stimulating agents such as erythropoietin find wide usage in cancer chemotherapy-related as well as kidney disease anemia, but concerns continue as to their thromboembolic risks.

This systematic review and meta-analysis found a significant reduction in perioperative allogeneic blood transfusions, also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. They found no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Dosing and timeframes in less heterogeneous populations may be needed but the results are encouraging.

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Substance use disorders in pregnancy

The results of a joint workshop provide guidance on all aspects of substance use in pregnancy. Issues discussed in the full free text include screening tests, biologic tests, management of pain in labor and after Cesarean, pain after discharge, and approaches to medication assisted therapy (Methadone and Buprenorphine are standards of care), and organizational issues to optimize care. Discussion around breast feeding and the common neonatal opioid withdrawal syndrome (NOWS) occurs.

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WHO Surgical Safety Checklist & Mortality

A large population cohort study in a surgical setting in Scotland finds a remarkable 36% relative decrease in perioperative mortality since implementation of the WHO Surgical Safety Checklist.

No such trend in improvement was observed in the non‐surgical cohort. While causality is always difficult to prove, no other baseline demographics changed to explain the results. Most importantly, “This study provides further evidence that the success of checklist implementation is more pronounced when it is supported by a cohesive and wider approach to patient safety”, and also stresses the importance of “creating a culture of communication and teamwork that supports patient safety”.

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Restrictive IV Fluid Trial in Severe Sepsis and Septic Shock (RIFTS)

A small randomized pilot trial compares restrictive vs. usual care fluid administration in severe sepsis and septic shock. It reflects increasing disquiet on the potential harms of excess fluids and their seeming endorsement in the Surviving Sepsis guidelines (although the latest revision allows vasopressors to be started simultaneously).

The restrictive group received significantly less resuscitative IV fluid than the usual care group (47.1 vs 61.1 mL/kg; p = 0.01) over 72 hours.

There were no differences in 30 day mortality, and no difference in hospital or ICU length of stay, organ failure or other serious side effects.

Recognizing this as a small pilot study, the authors recommend large multicenter trials to confirm these findings.

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Anesthetic Neurotoxicity in Children

This article discusses the issues raised by many studies of potential neurotoxicity of anesthetics in infants, toddlers and children.

It attempts to address varying results of different studies, and to synthesize animal evidence with pediatric studies, different times of exposure and number of anesthetics.

The authors note that test batteries may not have sufficient ability to detect subtle changes in IQ, behavioural issues and academic performance, and argue for a redirecting of testing to identify potentially subtle effects that could be related to anesthesia.

There are still no studies that show overwhelmingly that anesthesia causes harm in pediatric anesthesia and at this time no practice change is felt to be warranted for performing necessary surgeries in children

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Fentanyl and Post-Op Respiratory Complications

There has been a decrease in intraoperative opioid use due to the twin concerns of opioid induced hyperalgesia and acute opioid tolerance especially with short acting agents. Opioid free anesthesia is common with various combinations of agents like Dexmedetomidine, Lidocaine, and Ketamine.

The pendulum sometimes swings too far, as is echoed by laws and restrictions on opioid prescription resulting in inappropriate sudden opioid discontinuation.

This analysis evaluated the association of intraoperative fentanyl dose and postoperative respiratory complications within 3 days after surgery (defined as reintubation, respiratory failure, pneumonia, pulmonary edema, or atelectasis).

Intraoperative low-dose fentanyl (about 60–120 μg for a 70 kg patient) was associated with lower risk of postoperative respiratory complications compared with both no fentanyl and high-dose fentanyl. Beneficial effects of low-dose fentanyl were augmented in thoracic surgery, and with high dose inhalational anaesthetics and neuromuscular blocking agents. A randomized controlled study might clarify the significance of these findings.

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Brain Death Definition

Brain death has different definitions regarding the significance of whether all functions of the brain have ceased. This has ethical, religious, critical care, and organ donation implications. Anaesthesia journal discusses the concept.

The UK accept brain death as ”the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe… and therefore irreversible cessation of the integrative function of the brainstem” .

Canadian practice uses similar criteria to the UK. The CMAJ Guidelines recommend that: “neurologically determined death be defined as the irreversible loss of the capacity for consciousness combined with the irreversible loss of all brainstem functions, including the capacity to breathe

Similarly, the World Health Organization defines death as ”the permanent loss of capacity for consciousness and all brainstem functions, as a consequence of permanent cessation of circulation or catastrophic brain injury.”

However, the US uses the Uniform Determination of Death Act , calling for the irreversible cessation of all functions of the entire brain”, and that a determination of death “must be made in accordance with accepted medical standards.” These two requirements may clash!

That some electrical activity or functions of the brain could persist despite brain stem death has been the basis of legal challenges in the US. Adoption of the WHO definition would be optimal but that is unlikely to occur any time soon in the US.

The full text discusses legal cases in the UK, Canada, and the US.

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Cardiopulmonary exercise testing

Cardiopulmonary Exercise Testing (CPET) is increasingly used to assess risk and optimize planning before major surgery. Deficiencies in the CPET-derived variables anaerobic threshold, peak oxygen consumption, and ventilatory efficiency for carbon dioxide are associated with poor postoperative outcomes.

This educational article seeks to enlighten on the interpretation of the ‘nine-panel plot’ and enhance understanding of the results:

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Incentive Spirometry after CABG

The ubiquitous incentive spirometer for breathing exercise after surgery has often been questioned as lacking evidence. Many prehabilitation programs use structured deep breathing as well as inspiratory muscle strength training, along with aerobic and resistance training. Australian choosing wisely physiotherapy guidelines recommended against incentive spirometry ( link ).

This was a single center randomized trial in coronary artery bypass surgery which aimed to improve adherence by incorporating hourly reminder bells. The results were quite impressive in improved Incentive Spirometer use adherence, atelectasis severity, early postoperative fevers, noninvasive positive pressure ventilation use, intensive care unit length of stay by a day, and 6-month mortality rates.

“Incentive spirometers can be clinically effective, but perhaps only when adherence is high”. Further studies are recommended on incentive spirometry without reminders. As a relatively small trial, further larger studies with balanced patient populations are essential.

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Prevention & Management of Accidental Awareness

Awareness under general anesthesia is still encountered in situations not that rare. The Royal College of Anaesthetists and Association of Anaesthetists have issued this guidance on the topic, incorporating NAP5 evidence.

Discussion on approach to consent, anesthesia management, monitoring, and how efforts to minimize awareness takes place in the document. Special emphasis on the prudent use of neuromuscular blocking agents occurs.

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