Month: May 2018

Health News

Warning on benzocaine in infants and children, common in teething products  link

Severe atopic eczema linked to increased cardiovascular risk  link

Potential for weight gain from antidepressants  link

S100B as a biomarker for mild traumatic brain injury in children may be useful as part of initial assessment and lower CT radiation link

Ebola outbreak in DRC  link

Eggs and Nutrition – the circus continues. They’re good for you this week – just enjoy and don’t read any more studies  link

Despite the new formulation of the nasal spray flu vaccine, AAP still recommends flu shot  link

IBD, specifically Ulcerative Colitis may increase later risk of Parkinson’s  link

FDA approves Aimovig monthly injection for migraine, a monoclonal antibody that studies so far have only shown to be better than placebo link

 

Norepinephrine Infusion for Cesarean Spinal Hypotension

Phenylephrine has become the favoured agent for hypotension during spinal anesthesia for Cesarean and studies show that using a continuous prophylactic infusion works best and also lowers nausea and vomiting. link

Norepinephrine is a similarly acting agent and studies are appearing showing its utility in preventing hypotension. “A manually titrated infusion of 5 µg/mL of norepinephrine was effective for maintaining BP and decreasing the incidence of hypotension, with no detectable detrimental effect on neonatal outcome”.

Some dose ideas are present in this study. But it may take time and more studies to be adopted by anesthesiologists more familiar with its ICU use, as well as direct comparison with current agents.

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ECMO for ARDS

A randomized study sought to answer the continuing debate over the utility of early extracorporeal membrane oxygenation for very severe ARDS.

“Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy“.

Bleeding and thrombocytopenia were higher in the ECMO group and ischemic stroke less.

There was a clear trend to better mortality but not clinically significant, and the trial was stopped early for futility. Experts question the statistical design and cutoff point for futility. There was also a sizeable crossover to rescue ECMO in the control conventional ventilation group. The debate is unlikely to end, and ECMO will probably remain in the armamentarium of severe ARDS treatment in expert centers as a viable choice.

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Extracorporeal Pediatric CPR

A small retrospective study of 56 Pediatric cardiac arrests (80% related to primary cardiac conditions), mean age 3.5 months (1-53).

Survival to hospital discharge was a very good c. 65%, best in younger age (3.5 months) and those with decreased extracorporeal CPR tones and those exposed to therapeutic hypothermia. Follow up showed a good quality of life and family functioning. Further studies are needed to establish whether the technique should be more widely available in Pediatric critical care.

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Anesthesia Neurotoxicity

The ongoing concern continues, albeit somewhat controversial, that general anesthesia may be neurotoxic. This observational study on over 60 year olds found elevated Neurofilament Light and Tau for 6 hours and remaining high at 48 hours after surgery. They are both markers of neuronal damage. Correlation with clinical outcome would require further studies but clearly the entire area of potential anesthesia neurotoxicity, particularly in the developing infant and toddler brain, as well as in the elderly, will remain an important sphere of research and concern.

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Intubation in OR vs ICU

A Spanish study compares OR vs ICU intubation by direct laryngoscopy. Everything was somewhat worse in  the ICU: worse view, lower first attempt success, higher rate of difficult intubation and use of airway adjuncts,  and higher complication rate. They suggest that patient and environmental factors may be of more importance than the operator (even previously known easy intubations were more difficult in ICU). Despite all that, their success rate was better than other studies, which they attribute to high use of neuromuscular blocking agents, an increasingly recommended practice. Videolaryngoscopy has met with better success in many but not all studies.

At the least, greater preparation, optimized positioning and airway equipment,  and trained assistance should be available for non-OR intubation

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Acupuncture for Hip Osteoarthritis

A Cochrane review essentially finds little to no benefit for hip osteoarthritis acupuncture.

So many studies on acupuncture are confounded by poor methodology, placebo and expectation effects, sham acupuncture comparisons and multiple interventions. It is hard to find a convincing positive study and like many integrative practices, a driving factor seems to be to steer patients away from opioids.

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Liposomal Bupivacaine and Opioid Use

Strong marketing of liposomal Bupivacaine (Exparel) has occurred with its supposed long lasting effects. From local infiltration first, it was approved for nerve block based only on placebo comparison rather than existing regimes. This study of its use for total knee arthroplasty finds that liposomal bupivacaine was not associated with a clinically important reduction in inpatient opioid prescription, length of stay, or opioid-related complications in patients who received current multimodal pain management techniques including a peripheral nerve block. Its place in pain management has yet to be fully defined.

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