Month: February 2019

Upper Limb Disorders in Anesthesiologists

There are many hazards being recognized more often in anesthesia providers, like fatigue, stress, depression, burnout, suicide, needle injuries, and substance misuse.

A recent Association of Anaesthetists (UK and Ireland) online survey addresses upper limb musculoskeletal issues in anesthesiologists.

Thirty‐four per cent (n = 3884) reported they had a formal diagnosis of an upper limb disorder, with cervical disc prolapse/degeneration and rotator cuff tendinitis being the most common single diagnoses; there were significant associations between reporting upper limb disorders and the number of years since starting anaesthetic training, having children (irrespective of the number of children) and being right‐handed, these latter perhaps representing co-burdens.

It is readily comprehensible that poor ergonomics frequently occur in performing tasks like stooping during airway manipulation or central line insertion, and extreme spinal rotations occur in over-reaching even during neuraxial anesthesia.

The figures seemed high but there are limitations to the survey, which was limited to members only, response rate was 38%, and biases not accounted for. The whole biopsychosocial aspect of pain and disability is not encompassed. However efforts to improve ergonomics seem worth pursuing (videolaryngoscopy being one such improvement in overall non-stooping posture).

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Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair

This randomized study from the “green journal” compared preoperative intravenous acetaminophen 1g with placebo in women undergoing either laparoscopic or vaginal prolapse repair.

The findings were that “preoperative IV acetaminophen did not reduce pain scores or opioid use and had no effect on patient satisfaction or QOL. Routine use of preemptive IV acetaminophen alone is not supported by this study”.

This joins other studies showing little gain from intravenous acetaminophen.

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Medical and Health News Weekly

Health Canada catches up with recommendation to avoid opioid-containing (eg Codeine) cough and cold meds in kids link

Girls’ pain seen as less credible link

No, getting young blood or plasma infused will not prevent Alzheimer’s, FDA agrees link

Rapid sepsis diagnosis test hyped in media, despite absence of clinical trials (and a researcher hoping to attract funding) link

A plea to stop suggesting cannabis as an unsupported panacea for everything, like the opioid crisis link

A hip replacement can be expected to last 25 years in around 58% of patients, and about three-quarters of hip replacements last 15–20 years link

Shoulder replacement surgery failure rate and complex revision is on the other hand higher than expected link

Can Facebook curtail anti-vaccination misinformation or do quacks have freedom of speech? link

Pinterest acts to curtail anti-vaccination posts link

USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions link

Acupuncture recommended as an option for menopausal symptoms link

Delirium and Acetaminophen

A small but randomized study looked at delirium in older patients after on pump CABG.

It was found that postoperative scheduled IV acetaminophen (Paracetamol), combined with either IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Morphine use was lower. They suggest further research using oral acetaminophen and other opioid sparing techniques to address the huge issue of delirium. Incidence of side effects like hypotension should also be addressed.

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Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis

This randomized study in critically ill patients compared pharmacological prophylaxis alone with its used combined with intermittent pneumatic compression.

The authors found that adjunctive intermittent pneumatic compression did not result in a significantly lower incidence of proximal lower-limb deep-vein thrombosis than pharmacologic thromboprophylaxis alone.

Pneumatic compression may of course have a role in circumstances where anticoagulants may be inappropriate or contraindicated.

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Capillary Refill vs. Serum Lactate in Septic Shock

A randomized study compared capillary refill time with serum lactate guided treatment in septic shock.

They concluded that a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality, as 28 day mortalities were not significantly different.

Others might argue the two techniques were equivalent…

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Esophageal Pressure guided PEEP

It has become a common practice to titrate PEEP based on esophageal pressure (Pes), an estimate of intrapleural pressure. This allows calculation of transpulmonary pressure, defined as airway pressure minus pleural pressure, a more important lung stressor than simply using airway pressure.

In this randomized clinical trial of 200 mechanically ventilated patients aged 16 years and older with moderate to severe ARDS, PEEP titration guided by PES measurement was compared with empirical high PEEP-Fio2 titration.

There was no significant difference in a composite outcome that incorporated death and days free from mechanical ventilation through day 28.

The findings do not support esophageal pressure guided PEEP titration.

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Discussion of the nuances in this editorial

Anesthesia in Infancy and Neurodevelopmental Outcome

The ongoing topic of the potential harmful effects of general anesthesia on the developing brain is subjected to an international randomized study. Infants of less than 60 weeks’ postmenstrual age who were born at more than 26 weeks’ gestation undergoing inguinal herniorrhaphy, without previous exposure to general anaesthesia or risk factors for neurological injury were randomized to receive either awake-regional anaesthetic or sevoflurane-based general anaesthetia.

The primary outcome was FSIQ in the Wechsler Preschool and Primary Scale of Intelligence.

Conclusion: Slightly less than 1 h of general anaesthesia in early infancy does not alter neurodevelopmental outcome at age 5 years compared with awake-regional anaesthesia in a predominantly male study population.

This is another reassuring finding for the concerns promoted by animal, preclinical and observational studies on the same topic.

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Perioperative Fluid Therapy

A review (full text subscribe) surveys current views on perioperative fluid therapy.

The 2 hour clear fluid pre-operative guideline is now often encouraged rather than allowed. (Pediatric bodies have recommended 1 hour for clear fluids recently).

There is a discussion of volume status assessment, and the more difficult assessment of flow as opposed to blood pressure, but low CVP and inferior Vena Cava diameter respiratory variation using ultrasound are reviewed.

However the often neglected Straight Leg Raising Test is simple and elegant, ideally using a pulse contour device or esophageal Doppler to better reflect changes in SV; if unavailable, the effect on systolic blood pressure can be used. It can also be used during and after surgery.

Liberal and restrictive fluid regimens are discussed. Restrictive has become commonplace as part of enhanced recovery after surgery protocols (ERAS). However the caveats raised by the RELIEF study showed a higher kidney injury with restrictive regimes, leading to the suggestion of moderately liberal fluids for major abdominal surgery – in practice using about 2 to 3 litres intraoperatively.

The evidence that normal saline leads to increased kidney injury is discussed, so balanced solutions like Lactated Ringers or Plasmalyte are recommended.

The crystalloid vs. colloid debate is mentioned if only to to highlight its enduring controversial and unresolved nature, although there has been a shift away from colloids.

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