Haloperidol and Long Term ICU Outcome

This study examined the use of prophylactic Haloperidol in ICU patients at high risk of delirium. While it is often a treatment agent used when non-pharmacological approaches to delirium fail, this study confirms that prophylactic use exerts no beneficial effect on long-term quality of life in ICU survivors.

The REDUCE study previously showed that neither does it reduce the incidence or duration of delirium.

“The factors age, medical, and trauma admission, baseline quality of life, risk for delirium, and the number of sedation-induced coma days are associated with the decline in long-term outcome parameters.”

And a major message is “Every additional day of sedation-induced coma is associated with further decline of long-term physical and mental function”.

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Spinal Anesthesia Failure

This retrospective study analyzed the factors associated with spinal anesthesia failure in patients undergoing elective total hip or knee arthroplasty.

The factors associated with increased odds of spinal failure included younger age, lower BMI, hip arthroplasty vs. knee arthroplasty, needle insertion at L4-5 and L5-S1 vs. L2-3, 22-gauge needle size vs. 25-gauge needle, and hyperbaric bupivacaine vs. isobaric bupivacaine.

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Driving Pressure and Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome

Driving pressure is the difference between plateau pressure and positive end-expiratory pressure (PEEP), and is known to be associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). This has been demonstrated in controlled mechanical ventilation.

This study viewed it in the spontaneous ventilation/ weaning scenario. They established driving pressure and compliance could be reliably measured and an important finding that “Higher driving pressure measured during pressure support (assisted) ventilation significantly associates with increased intensive care unit mortality, whereas peak inspiratory pressure does not.”

Lower respiratory system compliance also significantly associates with increased intensive care unit mortality.

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Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty

This large national cohort “identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.”

Benzodiazepines and gabapentinoids were associated with higher odds of delirium, whereas lower risk of delirium was associated with neuraxial vs. general anesthesia, use of NSAIDs and COX2 Inhibitors, and high vs low opioid use specifically in the over 65 year olds.

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Postoperative Delirium and Long-term Decline in Activities of Daily Living

Delirium occurs all too commonly in the elderly after surgery, in a quarter of elderly patients after major elective and urgent major orthopedic surgery in this study.

The deleterious impact of delirium is well documented by now, although some studies do not prove causation versus association, but the conclusion adds more to this evidence:

“Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.”

The follow up occurred between 24 and 36 months after anesthesia and surgery.

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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Operating Room Humidity

Some ORs experience rises in humidity in summer. This APSF free answer to a query discusses the rationale and impact of working outside the generally recommended humidity levels 20 – 60%.

Low humidity could affect shelf life or generate electrostatic sparks. High humidity is uncomfortable for staff and could increase wound infection or cause mildew or mild in the longer term. The evidence on both fronts is sparse but equipment and supplies often specify ranges that prudent organizations adhere to, which may involve suspending operations.

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