Month: May 2018

Laparoscopic bariatric surgery mortality

Mortality rates from  laparoscopic bariatric surgery continues to fall with current rates lower than 0.25% , with the lowest rates for laparoscopic sleeve gastrectomy, at 0.11%

Risk factors for one year mortality included older age, male gender, high BMI, 30 day leak,  30 day hemorrhage, 30 day pulmonary embolism and these latter three need aggressive prevention and minimization.

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Fascia Iliaca Block for Elderly Hip Fracture

A recent narrative review encompasses more than nerve blocks, but an overview of the scale of the issue. Costing billions of dollars annually in a mostly elderly population, a third of whom have preexisting cognitive impairment, 30 day mortality is high c. 10% and perhaps 1 in 4 by 1 year, along with a continuing burden of illness; 25% need institutional care.

Pain assessment is difficult in cognitively impaired, and analgesia is way too often inadequate even though it brings its own dangers. Some evidence (still evolving) suggests regional analgesia may lessen medical complications, delirium, length of stay and even mortality, though this evidence is weaker.

The Fascia Iliaca nerve block has emerged as a favoured block in such patients.  Ultrasound guidance increases success. As part of a multimodal strategy, this block should be strongly considered in hip fracture.

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Epidurals in Labor Cochrane Review

Cochrane once again give their impassionate analysis of labor epidurals compared to other or no analgesia. They conclude that low quality evidence shows that it’s better analgesia than other forms, and seem to acknowledge that assisted birth is no more common with modern epidural techniques, nor is the rate of Cesarean increased. Backache long term is often attributed by patients to epidurals for which Cochrane found no evidence; it is obviously common in the population anyway. Neither did they see any links to short term neonatal Apgar status, and see a need for further studies on long term neonatal outcome, in both epidural and non-epidural groups.

Hypotension, motor blockade, urinary retention and fever were more common in the epidural group, but less respiratory depression and nausea/vomiting than opioid groups. Epidural first and second stages were longer and more likely to receive Oxytocin augmentation of labor.

Part of the confusion probably results from there being many different regimes of epidural analgesia, and many dysfunctional labouring women are more likely to request epidural, but the overall conclusion supports epidural analgesia as an effective option for pain relief.

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OSA and Opioid Prescribing

In surgical patients, a retrospective study showed a worrying rate of opioid prescribing (86%) at hospital discharge in patients with known or suspected Obstructive Sleep Apnea (OSA).

Such patients, many of whom are morbidly obese, are at increased risk of respiratory obstruction and depression, and guidelines (such as from the ASA) recommend closer monitoring as well as using multimodal non-opioid analgesia. Where opioid analgesia is required, the Society for Ambulatory Anesthesia advises against ambulatory surgery if pain control cannot be provided with predominantly non-opioid techniques in such patients. Even in-patients with OSA are frequently not properly monitored in high dependency units.

There is still clearly ample room for prescriber education in opioid risk evaluation and mitigation, and OSA patients are at special risk when discharged on opioids (and indeed even as in-patients).

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Enhanced Recovery Recommendations

The American Society for Enhanced Recovery releases a joint consensus on definition, management and prevention of postoperative gastrointestinal dysfunction.

It encapsulates many known protocols like low/no opioids, no NG tubes, minimally invasive surgery, Alvimopan where opioids are used, nausea/vomiting prophylactix, euvolemia and normal electrolyte balance, immediate eating and drinking, use of a combined isosmotic mechanical bowel preparation with oral antibiotics, and consider coffee/gum chewing.

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Tranexamic Acid and Intracerebral Hemorrhage

Tranexamic Acid has established a place for reducing bleeding in trauma, post partum, and in surgeries like orthopedic, neurosurgery, cardiac surgery.

The current trial in intracerebral bleeding found that while it decreased hematoma expansion and deaths by day 2 and 7, there was no difference in functional outcome at 90 days. There was no higher incidence of side effects like thromboembolism. The sample size can not rule out a beneficial effect in view of the early promising effects  and larger trials are needed.

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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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