Month: July 2018

Canadian Anesthesia Incident Reporting System

In compliance with WHO patient safety recommendations and other international initiatives, the Canadian Anesthesia Incident Reporting System (CAIRS) is now online at cairs.ca

It is an anonymous, confidential site whose input will be analyzed by experts who will in time deliver feedback to CAS members, to whom it is at present limited.

A full description is available here, link

 

Propofol vs. Sevoflurane and Neurocognitive Recovery

Hot on the heels of potential advantages using Propofol TIVA for better outcome in cancer surgery, a study found that in older adults undergoing major cancer surgery, propofol-based general anaesthesia decreased the incidence of delayed neurocognitive recovery at 1 week after surgery when compared with sevoflurane-based general anaesthesia. It also decreased the occurrence of perioperative tachycardia. A small single center study that will need further research in the whole area of anesthetics and outcome.

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Erythropoietin (EPO) in Cardiac Surgery

A retrospective study compares outcomes in cardiac surgery in those who declined transfusion and received EPO  with those who did not receive EPO or transfusion. Allowing for the limitations of retrospective design, they found no difference in mortality, MI, stroke, thromboembolism, kidney injury, extubation time, ICU or hospital length of stay. The results are encouraging for those who decline transfusion such as Jehovah Witnesses but further larger prospective trials are needed. EPO remains off-label for this use.

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Surgeon-Anesthesiology Relationship

Legendary patient safety advocate Jeffrey Cooper provides his observations on the impact of the surgeon-anesthesiology relationship on patient safety.

Anesthesiology : surgeons are ignorant of medical/anesthesia issues, underestimate surgical time and blood loss, fail to consider health conditions and patient desires, fail to inform of the likelihood of surgical success and magnitude of recovery.

Surgeon: anesthesiologists cancel easily, long turnover time, don’t appreciate scheduling, inattentive and poor communication of hemodynamics, just want to finish the day, don’t change anesthesia for surgeons’ needs.

Instead of an adversarial approach, he suggests an advance huddle on the premise that both presume competence, intelligence, knowledge and a patient interest focus on the part of the other. Where there is legitimate disagreement about what option to pursue, the debate would center on what’s right for the patient, not who is right.

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Blood: Choosing Wisely

Some recommendations of relevance to anesthesia and perioperative care on anemia and blood usage:

Delay elective surgery in patients who have correctable anemia

To reduce iatrogenic anemia, don’t order blood tests unless they are clinically indicated.

Don’t transfuse if there is no active bleeding or laboratory evidence of coagulopathy.

To manage surgical bleeding, use early antifibrinolytic drugs like tranexamic acid rather than blood transfusion if possible.

In nonemergent settings, avoid transfusion when other interventions are available. Discuss alternative strategies during the informed consent process.

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Medical News Weekly

Rapid rise in cirrhosis and liver cancer deaths in the US especially in the 25-34 year olds linked to alcohol.  link

Methotrexate ineffective for long term maintenance in ulcerative colitis  link

Cardiovascular Disease Population Risk Tool (CVDPoRT) based on sociodemographic and behavioural risks derived link

Low rates of osteoporosis treatment initiation after a hip fracture in recent years needs improving  link

The AAP expresses concern about food additives and child health, especially nitrates, nitrites, bisphenol and phthalates  link

Essure birth control to be no longer sold after reports of complications  link

Acupuncture associated with statistically significant reductions in aromatase inhibitor–related joint pain at 6 weeks in early breast cancer, although the magnitude of the improvement was of uncertain clinical importance  link

Trials on Sidenafil (Viagra) for intra-uterine grow retardation halted after deaths in babies  link

 

Programmed Intermittent Epidural Bolus

Programmed Intermittent Epidural Bolus (PIEB) along with patient controlled epidural analgesia was associated with shorter second stage of labor, less motor block and less local anesthetic use compared with continuous epidural infusion. There was no significant difference in mode of delivery, fentanyl dose, or maternal satisfaction. This study supports the increasing interest in PIEB for labor analgesia.

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Lactate + Shock Index and Postpartum Hemorrhage

Lactate has an established place in the diagnosis of sepsis but this study shows that in combination with the shock index it predicts massive transfusion in the ED in primary postpartum hemorrhage. When combining elevated lactate concentrations (>4.0 mM L−1) with a shock index >1.0, the specificity and positive predictive value were high. (Shock Index = Heart Rate / Systolic BP)

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Pre-Hospital Plasma for Shock

A trial compared standard resuscitation to thawed plasma resuscitation in patients at risk of hemorrhagic shock during pre-hospital air transport. There was a significant reduction in PT and more importantly in 30 day mortality in the plasma group. “No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions“.

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A similar study in a different setting – “during rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres”.   link

Dexmedetomidine Reduces Post-op Delirium

A systematic review and meta-analysis with trial sequential analysis of randomised controlled trials concludes that Dexmedetomidine reduces post-operative delirium. This agent is one of the few sedatives that can reduce delirium. “Evidence for dexmedetomidine’s influence on secondary outcomes (in-hospital mortality, intensive care unit and hospital length of stay, bradycardia, and hypotension) is thus far insufficient to draw conclusions.”

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