Month: July 2018

Medical News Weekly

Red meat consumption could be a risk factor for endometriosis  link

Y’all watch what you eat – Southern US Diet linked to higher mortality in heart disease  link

TPOXX (tecovirimat) approved for – smallpox!  Sign of the times with fear of bioterrorism  link

Heart failure higher in women, with different hospital admission rates and co-morbidities  link

Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology (Pap) testing resulted in a significantly lower likelihood of CIN3+ at 48 months  link

There is little or no effect of omega 3 supplements on the risk of experiencing heart disease, stroke or death, despite the hype   link

Unhealthy lipid profiles reduce parity  link

High normal blood pressure (but below treatment  thresholds) associated with later dementia  link

Among adolescents followed up over 2 years, there was a statistically significant but modest association between higher frequency of digital media use and subsequent symptoms of ADHD. NOTE! further research is needed to determine whether this association is causal  link

Fecal occult blood associated with higher all cause mortality from cardiac, respiratory, digestive, neuropsychological, blood and endocrine diseases – and not just colorectal cancer  link


Propofol and Cancer Survival

Speculative and theoretical evidence has suggested Propofol anesthesia has less effect on immune function and cancer spread and this study finds remarkable evidence to support that Propofol based TIVA (total intravenous anesthesia) in colon cancer surgery is associated with better survival compared to Desflurane anesthesia, 33% vs 15%.

Several caveats include a retrospective study design, TNM staging, lack of blood use data and potential selection biases. Nonetheless this hypothesis needs more study and it is not unreasonable to use TIVA for cancer surgery taking this and other circumstantial evidence into account.



Epinephrine for Out of Hospital Cardiac Arrest

Despite its central role in ACLS, the use of Epinephrine and outcome has been controversial. A major study finds “the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group”.

Postulated mechanisms include impairment of microvascular cerebral blood flow or possible reperfusion injury. So Epinephrine may improve survival but at a cost. The most important message to reiterate is how vital rapid CPR and defibrillation are.

nejm link

High Flow Nasal Oxygen & Length of Stay

The enthusiasm for high flow nasal oxygen continues unabated. This study was on high‐risk patients with pre‐existing lung disease (COPD, asthma, recent lower respiratory tract infection), heavy smokers or morbidly obese patients (body mass index (BMI) ≥ 35 kg.m−2), who were expected to stay longer in ICU and hospital due to increased respiratory complications after cardiac surgery.

When compared with standard oxygen therapy care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. The authors recommend routine use of high‐flow nasal oxygen after tracheal extubation in this cohort of patients and further testing of their hypothesis in large multi‐centre randomised trials.



Medication Diluents, Volume and Hyperchloremia

When prescribing intravenous fluids, physicians don’t always take into consideration the amount contributed by medications. In this medical ICU study, 63% of all fluids came from medication diluents. This is an important source of ‘fluid creep’ that must be considered in de-resuscitation strategies ( blog link ).

The study focuses on the higher incidence of hypernatremia when using normal saline compared with 5% Dextrose, with a non-significant trend towards higher acute kidney injury. There was no higher incidence of hyponatremia, glucose levels or Insulin requirements in the D5% group.

Intensivists should monitor both medication fluids and their relation to electrolyte levels, with the increasing recognition of the association between 0.9% Saline and potential kidney injury, as well as medication diluent impact on overall fluid balance.


Post-op Opioid Consumption

It would appear that opioid prescription post operatively is still excessive after abdominal surgery. “Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion”.  This study shows just how little opioid amounts are needed on average.



Cardiac Output Based Fluids for Kidney Transplant

A small study on fluids for deceased donor kidney transplantation compared esophageal Doppler based stroke volume optimization with conventional clinical practice. Complications and delayed graft failure were no different and the primary endpoint – amount of fluid given – did not significantly differ. Pending larger studies this does not support cardiac output based fluid administration during kidney transplantation.




Albumin and Cardiac Surgery Mortality

An observational study of on-pump cardiac surgery links the use of 5% Albumin to lower in-hospital mortality and lower 30 day readmission when Albumin + crystalloid was used compared to only crystalloid. Composite morbidity and acute kidney injury did not differ. Randomized studies would be needed to confirm these findings but Albumin seems to hold more promise than the now discredited colloids like hydroxyethyl starch.