Sedation and Neuromuscular Blockade after Cardiac Arrest

Different combinations of sedation and neuromuscular blocking agents were used post cardiac arrest with targeted temperature management: no blockade, scheduled, or as needed. It was found that cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders.

Shivering prevention, reduced oxygen consumption, harmful effects of sedation or other confounders are all postulated effects that will require further elucidation but there is a recent return to the use of judicious neuromuscular blocking agents in critical care.

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Inter-professional Labor Epidural Attitudes

This survey finds differences between nurses, anesthesiologists and obstetricians. Timing of an epidural was influenced by patient desire for an epidural, primigravid patients without membrane rupture, oxytocin infusion initiated, labor epidural in a previous pregnancy, and a difficult airway.

“Different provider groups vary in comfort when managing labor epidural analgesia.

Willingness to advocate for epidural placement may depend on the cervical dilation.

Providers consider patient-specific factors when determining suitability”.

The authors posit that opportunity exists for inter-professional education and collaboration.

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OSA Screening in Pregnant Obese

Pregnant patients 24-35 weeks with BMI > 40 were given Obstructive Sleep Apnea (OSA) screening questionnaires (Berlin, American Society of Anesthesiologists checklist, and STOP-BANG), and the Epworth sleepiness scale. They underwent overnight sleep apnea testing; 24% had OSA.

“Established OSA screening tools performed very poorly to screen for OSA in this cohort. Age, BMI, neck circumference, frequent witnessed apneas and highly likely to fall asleep while driving were most strongly associated with OSA status in this cohort.”

OSA screening tools may need to be refined in this population.

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Antibiotic Choice for E. Coli & Klebsiella Sepsis

Attempts are made to spare carbapenems like meropenem for Gram Negative blood stream infections  to discourage resistance but this study does not support the use of Piperacillin-Tazobactam for that purpose. “The MERINO trial make clear that piperacillin-tazobactam should no longer be considered an alternative to meropenem for definitive treatment of bloodstream infection due to ceftriaxone-resistant E coli or K pneumoniae.”

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Surviving Sepsis Update

The most recent update of the Surviving Sepsis guidelines ( blog link ) has engendered some controversy in implementing the 1-hour bundle. While there is agreement on prompt recognition and treatment of sepsis, disagreement has occurred with some aspects, such as the need for longer time to establish a diagnosis, avoiding unnecessary or inappropriate antibiotics or large fluid volumes, and the lack of clarity between sepsis and septic shock (e.g. discussion here link ).

Therefore the SCCM and ACEP have issued an interim statement advising that the 1-hour bundle not be followed in its current form pending review Statement

Proteinuria and Postoperative Kidney Injury

While proteinuria is well documented as a medical risk factor for morbidity, this retrospective review of pre-operative proteinuria in surgical patients finds: “Proteinuria was associated with postoperative acute kidney injury and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management”.

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Dural Sac Extent in Neonatal Caudal Block

An anatomic study in neonates sought to determine how close the dural sac was to the apex of the sacral hiatus, as this may lead to unintended spinal injection. Average distance in males was 10.9mm and 9.6mm in females; it increased with greater neonate length. Range was 4.9 -26.3mm.

“Anesthesiologists should be aware of the short distance between the sacral hiatus and the dural sac when performing caudal blocks, the shortest distance was 4.94 mm. Armed with this knowledge, caudal techniques should be modified to improve the safety and reduce the risk of complications, such as dural puncture.”

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Medical and health news weekly

A significant number of adults are too physically inactive  link

Keep kids in rear facing car seats until they reach the max height/eight limits  link

The earlier the onset of type 1 diabetes, the greater the cardiovascular and mortality risk  link

Questions being asked about conflicts of interest in top cancer researcher, he has since resigned  link

Prepare for flu season and get vaccinated early if you’re over 6 months  link

Some EpiPens have their expiry dates extended  link

Long term consequences of undescended testes include infertility and cancer  link

FDA seeks to address what is becoming an epidemic of e-cigarette use in teenagers
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Full fat dairy link to lower disease and death rate, but study involved wide age range, questionnaire design and at odds with current dietary guidelines leading to ongoing uncertainty  link

While folic acid before and during  pregnancy reduces neural tube defects, it does not prevent pre-eclampsia link

 

Crystalloids vs. Colloids in Surgical Hypovolemia

Immense concern has existed regarding the evidence that colloids, in particular starches, increase mortality and renal injury, especially in septic shock. A previous study in critical care however found no mortality difference ( link ). The present subgroup analysis was focussed on critically ill surgical hypovolemic shock needing surgery before or within 24 hours of ICU admission. Again, no difference in mortality or renal injury was found.

Nuances like differentiation between synthetic colloids and albumin, and potential benefits of balanced salt solutions were not addressed so once again, the debate will continue. In particular the results should not at this point be extrapolated to the different population of septic shock patients.

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