Month: February 2019

Perioperative Epidurals and Delirium

A secondary observational non-randomized analysis of the PODCAST trial found that “postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption”.

This study lends support to further randomized studies to study Epidural analgesia and delirium, even though previous work does not strongly support any particular form of anesthesia for delirium prevention.


Heart Failure and Surgical Mortality

Heart Failure is a recognized red flag for surgical risk. This retrospective study sought to quantify the risk in over 600,000 patients undergoing non-cardiac surgery. The findings showed that crude 90-day mortality for patients with heart failure and symptoms was 10.1%; for patients with heart failure and no symptoms, 4.9%; and for patients without heart failure, 1.2%.

The important message is that in heart failure even without symptoms, mortality is higher.


Medical and Health News Weekly

Some light exercise may help in concussion recovery link

Ultra-processed food linked to increased mortality link

eCigarette use in youths has erased recent years’ gains in tobacco use reduction link

Warning on rare lymphoma in breast implant patients link

Teenager cannabis use linked to depression in young adults link

Women with hip fracture less likely to receive geriatric or anesthesia consultation link

FDA issues warning letters to companies making false claims about dementia treatments and cures link

Glyphosate (eg. Roundup) again linked to non-Hodgkins lymphoma link

Panel recommends approval of esketamine nasal spray for resistant depression. Concerns exist… link

2019 child and adolescent immunization schedule released link

Global Safe Anesthesia

The APSF summarize the basic standards of anesthesia safety as iterated by the World Health Organization – World Federation of Societies of Anaesthesiologists, and the SAFE-T summit.

It estimates 5 billion people do not have access to safe surgery and anesthesia and advocates for basic training and competence in individuals dedicated to anesthesia, as well as the drive to make both pulse oximetry and capnography as basic universal standards of monitoring, if only aspirational for now.


Global Capnography

As the heading suggests, an editorial and article makes a plea to make global capnography available and affordable as a standard of care especially in low and middle income countries to prevent avoidable deaths from esophageal intubation.

Much progress has been made on global oximetry projects such as the ASA Lifebox and other western countries supplying pulse oximetry to low and middle income countries, a standard of care (aspirational sometimes) of anesthesia. Now the effort is on to also make capnography a basic standard, which will recognize esophageal intubation or obstruction/ ventilation failure faster than the oxygen saturation shows.

Both monitors are recommended in the recently published World Health Organization – World Federation of Societies of Anaesthesiologists (WHO‐WFSA) standards.


General Anesthesia for Cesarean

This retrospective study spanned a decade but included nearly half a million Cesarean Sections in New York State.

5.7% were classified as GA without a recorded indication. The study found: “The use of potentially avoidable general anesthesia in these patients is associated with an increased risk of anesthesia-related complications, surgical site infection, and venous thromboembolism, but not death or cardiac arrest”. The odds were quite significantly higher.

Risk factors for GA included age less than 19, racial or ethnic minority, Medicaid or Medicare beneficiaries, preexisting or pregnancy-associated conditions, nonelective admission, and admission during weekend, teaching hospital, neonatal level-of-care designation 1 or 3, lower use of neuraxial techniques during labor and vaginal deliveries, higher annual volume of deliveries, and higher proportion of women with a comorbidity index greater than 2.

Neuraxial anesthesia is established as the standard of care in Cesarean anesthesia absent contraindication. Higher labor epidural rates appeared to be the most actionable factor to encourage and increase the odds of neuraxial anesthesia.

Many of the other factors are either known or subject to the limitations of this retrospective study, and may be subject to coding inaccuracy, malfunctioning epidural catheters, or patient request.


Routine Preoperative Testing for Cataract Surgery

This Cochrane review summarizes the evidence that has been found in that “Preoperative medical testing did not reduce the risk of medical adverse events during or after cataract surgery when compared to selective or no testing”.

There was no difference in medical adverse events, cancellation rates or eye complications. Costs however were 2.5 times higher.

Although the findings do not preclude specific circumstances, the overall findings do not support preoperative testing before cataract surgery as medically or economically effective, despite the usually older population with frequent comorbidities.


Cholecystectomy during Pregnancy

There has been a general opinion and comfort level with the safety of gall bladder surgery during pregnancy. One of the more reassuring findings in this study is that 90% were done after pregnancy, as the findings are not entirely supportive of existing recommendations.

They found “Women who have their gallbladder removed during pregnancy are more likely to experience longer hospital stays, increased 30-day readmissions, and higher rates of preterm delivery than those who delay the operation until after childbirth”. Pre-eclampsia and hemorrhage rates were also higher, as was open surgery.

It should be noted that they only studied third trimester vs. postpartum and not earlier during pregnancy. It certainly is possible that a subset of patients could benefit from cholecystectomy during pregnancy.


ECMO and ARDS Outcome

This was a prospective study on 84 patients with severe ARDS. They found: “In a single-center cohort of acute respiratory distress syndrome survivors, management with (vs. without) extracorporeal membrane oxygenation (ECMO) resulted in similar survival at 1 yr, pulmonary function, and computed tomography lung imaging, but less impairment in quality of life”.

This counts as a win for ECMO as those patients were more severe at admission. Quality of life is also now an extremely important patient related outcome that deserves attention.