Weekly Medical News

Marriage confers lower cardiovascular risk!  link

WHO declares compulsive video gaming an addictive behaviour disorder.  link

American Academy of Pediatrics condemns Border Security and Immigration Reform Act ‘s impact on children. link

Methadone and Buprenorphine reduce mortality after nonfatal opioid overdose  link

Generic Suboxone approved in US  link

Do viruses play a role in Alzheimer’s ?  link

NSAID use around conception was associated with increased risk of miscarriage link

High risk of death from  drug and many other causes  after non fatal opioid overdoses.  link

 

Spinal Bupivacaine and Fentanyl and Fetal Heart Rate

A study suggests that hyperbaric bupivacaine in combination with Fentanyl may produce more increase in uterine tone and fetal heart rate abnormalities than bupivacaine alone. These changes were short lived and the clinical significance is controversial but as there was no difference in analgesia, they suggest Fentanyl may be either unnecessary or doses could be lower in the spinal component of CSE.

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Dexmedetomidine Reduces Delirium

Another study continues to support the promising role of Dexmedetomidine as an agent to reduce delirium in the surgical population. This meta-analysis in the BJA concludes: “Dexmedetomidine may reduce postoperative delirium incidence for adult cardiac and non-cardiac surgical patients. The optimal dose and timing of dexmedetomidine and influence on other outcomes or particular patient populations with risk factors warrants further studies”.

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Perioperative Peripheral Nerve Injury After General Anesthesia

A review article discusses the incidence, mechanisms, diagnosis and prevention of peripheral nerve injuries during general anesthesia. It is an area still in evolution, as it is found that anesthesia care is appropriate in 90% of cases. Concepts such as ischemia, inflammation, “double crush”, mechanical factors are discussed as well as evoked potential monitoring like SSEP, nerve conduction studies and EMG.

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Intravenous Acetaminophen in Colectomy

A retrospective study of the use of iv Acetaminophen for open colectomies found that about 25% received it, half of whom only a single dose, but any benefit compared to oral Acetaminophen was marginal; oral acetaminophen appeared superior when using more than 1 dose on postoperative day 1.

There is a large cost difference. This study used data from the Premier Healthcare Database. Pending further perhaps randomized studies, and allowance for multimodal and regional analgesic techniques, there is little economic or analgesic advantage to using intravenous Acetaminophen compared to oral.

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The findings echo what was found in the ER setting – blog link

 

Clinical Frailty Score and Outcome

Frailty assessment should now be as much a standard as cardiorespiratory evaluation pre-op. No gold standard exists and one qualitative tool is the Clinical Frailty Scale – CFS link

This study on unscheduled surgeries in those over 65 years of age used the CFS as well as other outcome prediction tools.

It found that duration of hospital stay was independently associated with: pre‐operative ASA physical status; surgical severity; peri‐operative E‐POSSUM score; and SORT. Duration of stay was also associated with the CFS, but not independent of these variables.

Future refining of frailty assessment tools may lead to better prediction scales.

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Processed EEG and Delirium

Postoperative delirium is associated with increased length of stay, increased rates of institutionalization after discharge, mortality, and long-term postoperative cognitive dysfunction. Several processed electroencephalogram monitors are available such as the BIS, SED-line, Narcotrend, GE Entropy and SNAPII.

The use of these proprietary technologies has been advocated to reduce excessive anesthesia depth on the one hand, and prevent awareness on the other. Both NICE in the UK and the ASA stop short of fully endorsing them, but issue a qualified recommendation in individual high risk cases.

Postoperative cognitive dysfunction is variously defined and may be on the spectrum of delirium or a discrete entity and its heterogeneity in studies made analysis not feasible. As for delirium, this meta-analysis suggests that delirium risk may be reduced by the use of processed EEG. Whether the values obtained are modifiable or markers for at-risk patients is unclear, nor is it apparent that such patients received less anesthesia.

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Melatonin agonist, ICU stay duration and Delirium

Daily Ramelteon, a melatonin agonist, tended to decrease ICU length of stay, and the secondary important endpoint of delirium rate and duration was significantly reduced. In addition in the non-intubated group, there were fewer awakenings per night and a higher proportion of nights without awakenings. Further studies of this potentially important intervention are needed, as perhaps only Dexmedetomidine has appeared as the only useful agent to date in ICU delirium.

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Obstetric Failed Intubation

A literature review since 1970 of failed obstetric intubation at Cesarean delivery under general anesthesia reveals some themes.  Some salient features that emerged were the increasing tendency to continue GA usually with supraglottic airways, especially second generation devices like the ProSeal LMA.

The conflicting priorities of urgency, safety, maternal and fetal wellbeing make the decision on how to proceed difficult. Front of neck airway scenarios were sparse, but they are often done too late. There is surprisingly no data on videolaryngoscopy use in this review.

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