Month: November 2018

Medical & Health News Weekly

1 in 40 US children have Autism Spectrum Disorder diagnosis, per parents link

Trazodone is not a uniformly safer alternative to atypical antipsychotics, given the similar risk of falls and fractures among older adults with dementia  link

Biocell textured breast implants under scrutiny link

Faulty medical implants are harming patients globally due to poor regulations link

Unpublished (and unverified) reports of gene edited babies in China causing deep ethical concerns  link

China suspends same gene editing scientists link

Life expectancy down again in US driven by drug overdose and suicides link


Safe Anesthesia Medication Handling

Anesthesia is unique in terms of rapid injection of multiple medications often in a time critical fashion, and it is reported that medication error occurs 1-in-133 administrations. The authors of this Anaesthesia editorial argue for making safe medication handling a core competency in training. They also make several safety suggestions:

Handle one medication at a time.

Avoid distractions while preparing medications.

Check every vial  twice, once before drawing up and once after labelling

All syringes, including iv bags are labelled, ideally with standard colour‐coded labels.

Standard order and syringe sizing for each medication type

Do not draw up medications until they are needed.

Use a red‐barrelled syringe for NMBAs and draw up the whole ampoule into syringe (not available everywhere)  and never reuse a red‐barrelled syringe for reversal; do not place on work surface at the same time as reversal agents

Medications for emergencies, non-IV use, or specific purposes are not kept in the same place as i.v. medications.

All i.v. access points must be flushed or have a running i.v. line before leaving the OR

All medication‐related adverse events must be reported via an incident reporting system.



Buprenorphine Peri-Operatively

A review on managing Buprenorphine in the perioperative period notes the disparate views and protocols in use ranging from continuing it to weaning off and replacing with full agonists. The overall conclusion is that the ‘main impetus for discontinuation, i.e., inadequate pain management, may be based on expert opinion and not on the existing evidence’…”no evidence against continuing buprenorphine perioperatively, especially when the dose is < 16 mg SL daily.

The authors recommend that future studies require standardized reporting of median doses, details on the route of delivery, dosing schedules and any dosing changes, and rates of addiction relapse, including long-term morbidity and mortality where possible”.

Consultation with the prescribing expert in substance use would seem highly advisable when such patients present to us to balance the probable greater need for analgesics with safety and relapse potential.



Dexmedetomidine & Anesthesia

Two encouraging studies on Dexmedetomidine. The first reviews the potential for less neurotoxicity on its own or when added to other anesthetics, although more study is needed to assess any long term effects in children.

The second study reviews its use in general anesthesia and finds less pain and opioid use in adults postoperatively.

PedAnes link

ClinJPain link


Recovery without PACU

It comes as a surprise to read that only 16% of Japanese hospitals have a Post-Anesthesia Care Unit (PACU).

This study compared recovery times in a US hospital with a Japanese hospital, where the anaesthesiologists recover a patient in the operating room, showing 112 minutes (US) vs. 22 minutes (Japan). It would appear that Japanese anesthesiologists modify technique to expedite recovery at the expense of higher costs, using TCI Propofol, Remifentanil  and shorter agents, BIS monitoring and Sugammadex reversal.

It is suggested that where PACU over-capacity situations occur, the results may inform both anesthetic technique as well as case scheduling based on recovery needs. It may also be applicable to the practice of fast-tracking – bypassing PACU in selected cases.



Management of Anesthesia for Sickle Cell Disease

An educational article on anaesthesia management for children with sickle cell disease.  End-organ damage like cerebrovascular disease, heart failure secondary to thrombotic disease or pulmonary hypertension is seen less frequently now as is chronic kidney disease caused by ischaemic damage and loss of renal tubules. Vaccination should be comprehensive. The most common acute complications are infection and vaso-occlusive episodes. “Multiple splenic microinfarcts secondary to sickling is an early complication, with 90% of affected children reported to have functional asplenia by age 6 yr. This leads to an increased risk of bacterial infections, most notably with S. pneumoniae in addition to atypical organisms”.

Sepsis is less common with vaccination. The most common postoperative complications are vaso-occlusive episodes and Acute Chest Syndrome, reported especially after appendectomy and Cesarean, but also high after umbilical hernia repair, cholecystectomy, and splenectomy. Stroke and death were reported more rarely.

Anesthesia goals are to maintain oxygenation and hydration, avoid acidosis, and maintain normocarbia, normotension, and normothermia, as well as adequate analgesia.

Bja link


Fibromyalgia Diagnosis

The lack of understanding or ignorant denial of fibromyalgia as a diagnosis is hopefully disappearing. These new diagnostic criteria establishes a multidimensional diagnostic framework for chronic pain

The new core fibromyalgia criteria are multisite pain along with fatigue or sleep problems.Other dimensions of fibromyalgia, such as comorbidities, improve fibromyalgia recognition – they include irritable bowel syndrome, chronic pelvic pain and interstitial cystitis, chronic head and oro-facial conditions such as temporomandibular disorder, otologic symptoms, chronic headaches and migraine disorder, and psychiatric symptoms.

This comprehensive overview discusses the pathophysiology, risk factors, epidemiology and diagnosis of fibromyalgia.



Pediatric Maintenance Intravenous Fluids

The American Academy of Pediatrics issues a clinical practice guideline on maintenance intravenous fluids in children, also applying to postoperative settings. The long review highlights in particular the potentially lethal danger of hyponatremic encephalopathy from hypotonic fluids that were historically popular in children (and still advised in some textbooks). In brief, they state: “The AAP recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride (KCl) and dextrose because they significantly decrease the risk of developing hyponatremia”. 

They note for the purposes of this guideline, isotonic solutions have a sodium concentration similar to PlasmaLyte, or 0.9% NaCl. Recommendations are not made regarding the safety of lactated Ringer solution. Researchers in the majority of studies added dextrose (2.5%–5%) to the intravenous (IV) solution.

The review excluded patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who were younger than 28 days old or in the NICU.

guideline link

{Treatment guidelines for hyponatremic encephalopathy link }


LMA Protector and i-Gel Fibreoptic Intubation

The LMA Protector is a recent addition to supraglottic airways that also allows intubation as it lacks the epiglottic elevation bars in traditional LMAs ( link ).

Fibreoptic‐guided tracheal intubation is possible without the intermediate step of an Aintree Catheter and this study compared the LMA Protector with the I-gel. There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups.



Obstetric Epidural and Body Temperature

Epidural anesthesia is conventionally thought of as causing heat loss due to lower limb vasodilation from sympathetic blockade. This may be the case also in elective Cesarean epidurals.

Heat production is increased by both labor and epidurals. In this study in emergency Cesarean Section, after labor epidural top-up there was a progressive rise in temperature and after considering many mechanisms of heat production and hemodynamic mechanisms, the most likely explanation is limitation of cutaneous heat loss via blockade of active cutaneous vasodilation. (Cutaneous vasomotor tone is regulated both by the noradrenergic ‘active vasoconstriction’ pathway and the cholinergic ‘active vasodilation’ pathway).

“It is likely that heat loss limitation was responsible for the rise in mean body temperature before and after epidural top‐up, with heat production and heat loss becoming uncoupled”. Despite this, and not conflicting with this theory, cutaneous blood flow did not increase.

The authors caution that this study specifically dealt with epidural labor analgesia conversion to anesthesia via top-up for emergency Cesarean without major blood loss. However the use of active warming in this population could be questioned, much as prevention of hypothermia has become standard.

The subject is non-trivial as we are reminded: “Epidural hyperthermia (or fever) is a harmful condition which is associated with adverse neonatal neurological outcomes, an increased risk of operative delivery, and an increased risk of maternal and neonatal sepsis evaluation and treatment. Its underlying mechanism remains unclear. An association has been demonstrated with maternal inflammation, but no causal link has been uncovered”