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.



ICU Metabolic Acidemia and Bicarbonate

A randomized study on the use of bicarbonate for metabolic acidosis in critically ill patients. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7.  Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score

“In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury”.

lancet link

Appendectomy Delay

This meta-analysis might provide some considerations for discussion with surgeons on appendectomy timing.  The authors conclude “delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis“.  The feared perforation may actually be an early occurrence. Of course patient symptoms and comfort should enter into the equation, as well as discussion of antibiotic conservative approach.



Weekly Medical News

Vitamin D supplementation may improve fetal and infant growth  link

Removal of adenoids or tonsils may possibly lead to higher long term infectious, respiratory and allergic illness  link

Long term albumin in decompensated cirrhosis may improve survival  link

CRISPR gene editing technology not quite ready for prime time as a potential for cancer found  link

Resistance exercise may reduce depression symptoms  link

Many common medications list depression as side effect  link

A clear (and sometimes not so clear) analysis of the entirety of dietary research and the connection of different diets and diet components to chronic disease  link

And a look at the evidence of the popular topic – microbiome or microbiota on health link

Bisphosphonates are overwhelmingly useful but an article discusses the risk of atypical femur fracture link

Psychedelic drugs may have a future role in mental illness and addiction  link


Cesarean Spinal vs. Combined Spinal-Epidural

A literature search and analysis found no difference in spinal vs. combined spinal-epidural (CSE) for Cesarean in terms of sensory height, recede time, hypotension, vasopressor use, nausea and vomiting. A longer block time noted in the combined spinal-epidural group found, as might be expected.

Much uncertainty remains as to how different trial populations were managed e.g. lower intrathecal doses, epidural catheter use, post-op catheter use, and the individual circumstances that might prompt CSE use. Many anesthesiologists would still opt for CSE for anticipated longer surgeries or to use lowers spinal doses and also to have a rescue option rather than GA.  As a routine practice however, there seems no great advantage over spinal for Cesarean. This was not a study of CSE in labor analgesia.



Surgery Link to Opioid Misuse Potential

Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. Later it falls to family practice. This study emphasizes the role of postoperative opioid prescription and its renewal by family doctors as an important target for identifying risks of dependence and misuse.



Bicuspid Aortic Valve and Mitral Valve Prolapse

In recent years the guidelines for bacterial endocarditis antibiotic prophylaxis have been drastically curtailed. This Spanish study calls for reconsideration, in that patients with bicuspid aortic valves and mitral valve prolapse had viridans endocarditis with a similar profile to other high risk endocarditis cases.



Preoperative carbohydrate loading

In addition to more liberal guidelines for clear fluids in recent years, preoperative carbohydrate drinks have become popular and perhaps ahead of the evidence but seem to improve well being, speed of recovery and insulin sensitivity. A Cochrane review ( link ) found positive benefits.

This Pediatric study showed reduced nausea and gastric content (but not vomiting) after gastroscopy under GA with preoperative carbohydrate drinks.