Month: December 2018

Weekly Medical and Health News

A more flexible and patient focussed Canadian guideline on breast cancer screening  link

New CMA Code of Ethics  link

Roux-en-Y gastric bypass leads to the greatest weight loss, but sleeve gastrectomy has the lowest 30-day adverse event rate  link

First Nations children in Canada show higher pain indicators but see pain specialists less  link

Radical prostatectomy reduces mortality among men with clinically detected localized prostate cancer  link

Fentanyl surpasses Heroin as deadliest drug in US  link

Childhood trauma/abuse associated with psychosis in adolescents and young adults  link 

Johnson & Johnson reportedly knew for decades that there was asbestos tainting in their Baby Powder – now the cancer link lawsuits may make more sense  link

UK chain restaurants provide meals as bad nutritionally as fast food – including way more calories!  link

Infection Control in Anesthesiology

The Society for Healthcare Epidemiology of America has issued expert guidelines for infection control in Anesthesiology, a subject often shown to performed suboptimally. The ASA has summarized the recommendations and include the full link:

  • Hand hygiene should be performed, at a minimum, before aseptic tasks, after removing gloves, when hands are soiled, before touching the anesthesia cart, and upon room entry and exit. The authors also suggest strategic placement of alcohol-based hand sanitizer dispensers.
  • During airway management, the authors suggest the use of double gloves so one layer can be removed when contamination is likely and the procedure moves too quickly to perform hand hygiene. The report also recommends high-level disinfection of reusable laryngoscope handles or adoption of single-use laryngoscopes.
  • For environmental disinfection, the guidance recommends disinfecting high-touch surfaces on the anesthesia machines, as well as keyboards, monitors and other items in work areas in between surgeries, while also exploring the use of disposable covers and re-engineering of the work surfaces to facilitate quick decontamination in what is often a short window of time.
  • IV drug injection recommendations include using syringes and vials for only one patient; and that injection ports and vial stoppers should only be accessed after disinfection.


STOP-BANG Questionnaire and Outcome

The STOP-BANG questionnaire is a validated tool for Obstructive Sleep Apnea screening but this study sought to validate it as a predictor of complications after non-cardiac surgery. 

It had modest construct validity (correlation with ASA status, Revised Cardiac Risk Index, Charleston Comorbidity Index). However its predictive validity was not confirmed in that it did not predict postoperative mortality, hospital length-of-stay, or cardiac complications.


Cerebrovascular Autoregulation and Delirium

Delirium occurs in up to 50% of patients after cardiac surgery.  Previous studies have shown an association between impaired cerebrovascular autoregulation during cardiac surgery and delirium. This study found an association between impaired cerebrovascular autoregulation, measured by near‐infrared spectroscopy, and delirium in the early postoperative period. The postulation is whether individualized, cerebrovascular autoregulation‐guided blood pressure management during cardiopulmonary bypass can reduce postoperative delirium and stroke. 


Cricothyroid Membrane and Head Position

It has been recommended to mark the cricothyroid membrane with or without ultrasound pre-induction in an anticipated difficult airway to facilitate a surgical airway in an unfolding emergency. 

This study shows that it better to do this with the neck fully extended as the position significantly moves as the head is put in this recommended position for surgical airways. It also opens the membrane more to facilitate the advises size 6 tracheal tube insertion. 


Anaphylaxis to intravenous gelatin solutions

While starch based solutions have been popular in North America, gelatin based solutions continue to be used in other countries as colloids for hypotension or hypovolenia, despite little evidence. They include Isoplex, Volplex and Gelofusine.

Starch based solutions have fallen out of favour from concerns of renal injury and mortality in critical care. This report on anaphylaxis to gelatin solutions may also lead to a similarly diminished use. The reactions are described as insidious but severe hypotension, and one death. There seems little rationale for their ongoing use based on evidence of effectiveness.



Perioperative Vision Loss and Spine Surgery

Perioperative Vision Loss and Spine Surgery:

2019 Update on this issue of concern in surgery of the spine in the prone position. Risk factors include hypertension, diabetes, peripheral vascular disease, coronary artery disease, previous stroke, carotid artery stenosis), obesity, and tobacco use, as well as male sex. It is advised to inform patients in whom prolonged procedures, substantial blood loss, or both are anticipated that there may be an increased risk of perioperative visual loss. 

Advice is offered to maintain blood pressure, and higher in those with hypertension. Deliberate hypotension should be avoided unless deemed absolutely essential. Head position should be at or above head level in a neutral position. Crystalloid or colloid alone or in combination can be used and blood products given based on hematocrit.

Adrenergic agonists may be used on a case-by-case basis when it is necessary to correct for hypotension. Procedures may need to be staged. 


Weekly Medical and Health News

NHS in UK to offer 800 Calorie diet for Type 2 diabetes  link

ACOG:  “bed rest is not effective for the prevention of preterm birth & shouldn’t be routinely recommended  link

ASH guidelines on venous thromboembolism  link

Dementia is often misclassified when using brief cognitive assessments, largely due to test specific biases  link

Videolaryngoscopy beats direct in ED cardiac arrest  link

Live birth after uterus transplant from deceased donor  link

Sleeping too much associated with increased cardiovascular risk  link

Another instant all cancer detection test! Beyond the hype, it has never been used clinically or in humans  link

Hysterectomy may impair memory. But the study is in a rat model link

Anesthesia and Brain Health

An international consensus statement on postoperative brain health discusses current evidence on Perioperative Neurocognitive Disorder (PND) in older patients (> 65).

Much of the evidence is inconclusive at present regarding best anesthesia or preventative strategies. No specific agent or regional anesthetic has been found consistently superior, and processed EEG such as BIS  have not universally proven effective. However raw EEG may have a place despite its complexity at present. Brain perfusion if only in terms of maintaining mean arterial pressure is essential.

Baseline preoperative cognition should be assessed and documented, and consent should encompass the risks of delirium and PND.

full text link