Aspirin for Thromboembolism Prophylaxis

“Aspirin alone may be an appropriate alternative to other pharmacologic prophylaxis in preventing VTE for patients undergoing total knee arthroplasty.”

So says this JAMA study but with the limitations of retrospective analysis and the subtleties of non-inferiority design. Nonetheless it adds to the debate and evidence on the use of aspirin alone as a potential strategy (which would also simplify neuraxial anesthesia concerns with anticoagulation).

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Perioperative Acute Kidney Injury

An update article surveys the complex interplay of factors affecting kidney function in the perioperative period, discussing hemodynamics, fluids, diuretics, serum markers etc. “The Kidney Disease: Improving Global Outcomes guidelines suggest implementing preventive strategies in high-risk patients, which include optimization of hemodynamics, restoration of the circulating volume, institution of functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia.”

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Another study links intraoperative oliguria to acute kidney injury, in contrast to previous work. This presents a conundrum in an ERAS era of restrictive fluid administration. Oliguria should should at least direct closer monitoring of renal function especially in those with risk factors, along with minimizing nephrotoxic sgents.

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Weekly Medical and Health News

HPV vaccine fear-mongering dealt a blow – no increase in risky behaviours after vaccination  link

Rivaroxaban approved for reducing cardiovascular risks in coronary artery or peripheral vascular disease  link

Medicinal cannabinoids offer limited benefit in Multiple Sclerosis. But cannabis thrives on hype rather than evidence!   link

Cannabis becomes legal in Canada link

Acute flaccid paralysis, or myelitis, affecting many US children in polio-like illness  link

Aspirin use in healthy elderly persons did not prolong disability-free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo  link

Cannabis and tobacco products frequent in hip-hop music videos, and may be negatively influencing youths  link

Major cardiac stem cell paper retraction from Harvard and Brigham and Women’s  due to falsified and/or fabricated papers from Dr. Anversa  link

Potential link between cannabis and stroke presented  link

Most older people open to reducing number of medications and de-prescribing  link

Tamoxifen in early breast cancer increases risk of thromboembolism  link

High urate levels that often precede gout are more genetic based than dietary  link

 

Cricoid Pressure and Aspiration

A study throws doubt once again on the utility of cricoid pressure in preventing aspiration of gastric contents.

“The inclusion criteria were patients 18 years and older with a full stomach (<6 hours fasting) or the presence of at least 1 risk factor for pulmonary aspiration (emergency conditions, body mass index >30, previous gastric surgery [sleeve, bypass, or gastrectomy], ileus, early [<48 hours] postpartum, diabetic gastroparesia, gastroesophageal reflux, hiatus hernia, preoperative nausea/vomiting, and pain)”.

There was no difference in aspiration compared with a sham procedure but cricoid made intubation slower and more difficult. The authors caution that further study is needed in Obstetrics and outside the Operating Room.

However this study had a non-inferiority design that was underpowered with the low aspiration rates as well as defining a 50% difference threshold. It is unlikely to consign cricoid pressure to the history books but will perhaps confirm biases in the anti-cricoid camp!

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Post-Operative Atrial Fibrillation

Post-operative atrial fibrillation has been viewed as a transient or more benign phenomenon than non-valvular atrial fibrillation in chronic settings. This registry study showed that it occurred in 0.4% after non-cardiac surgery, more common after thoracic, vascular and abdominal surgery, and more likely in older patients with co-morbidities. After follow-up for some 3 years, the rate of thromboembolism was similar to those with non-valvular atrial fibrillation.

The authors recommend reconsideration of guidelines for anticoagulation in these patients at risk of thromboembolism and stroke.

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Anticoagulants and antiplateles in hip fracture surgery

Delay in hip fracture surgery can increase mortality (link ).

A Scottish Consensus statement on the management of patients on anticoagulants (and antiplatelet agents) presenting for hip fracture surgery incorporates current knowledge and views on when to proceed and how to expedite anticoagulant reversal with Vitamin K and/or Prothrombin Complex Concentrate, as well as antiplatelet agent considerations. Caution may also be needed with neuraxial techniques in such patients.

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Cannabis based medicines for chronic pain

A cautionary tale on cannabis use and users paralleling opioid users for questionable benefit. It is unlikely that cannabinoids are highly effective for chronic non-cancer pain.

“The absence of any clinically relevant beneficial effects of CBM in most systematic reviews, the presence of clinically relevant side effects, and the concerns about long-term risks, make it the duty of physicians prescribing CBM for chronic pain conditions to document and monitor patients carefully by following recent clinical practice guidelines.”

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