Month: April 2019

Ventilation in patients with intra-abdominal hypertension

A full text review on ventilation in intra-abdominal hypertension.

Intra-abdominal hypertension (IAH) is defined as a sustained increase in intra-abdominal pressure (IAP) equal to or above 12 mmHg. IAH affects the brain, the cardiovascular system and the lungs.

The average incidence of IAH in critically ill patients is around 25–30% on admission, and the cumulative incidence is around 50% during the first week of ICU stay. There is an association between IAH and respiratory failure.

IAH is associated with a decrease in lung volumes, a decrease in chest wall compliance, and abdomino-thoracic pressure transmission, while decompressive laparotomy results in an improvement in lung volumes.

The presence of IAH affects lymphatic drainage between the thoracic and abdominal cavity and may play an important role in the development of edema formation.

The article discusses recruitment maneuvers, PEEP, protective lung ventilation, prone positioning, hemodynamic changes, and the Abdominal Compartment Society guidelines for managing IAH or abdominal compartment syndrome.

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QI Program to improve survival – EPOCH trial

This study examined the effectiveness of a national quality improvement (QI) programme in the UK to implement a care pathway to improve survival in emergency abdominal surgery.

The conclusions were not positive!

“No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care”.

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i-gel® insertion and cricothyroid membrane identification

This small study examined cricothyroid membrane identification in adult females, whose anatomy is less pronounced than males. They concluded:

“The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy”.

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Lymphedema Risk And IV Placement

Recently reposted by the APSF, post-mastectomy lymphedema is a burdensome and sometimes intractable risk that has led to the advice to avoid all intravenous placements and blood pressure recording on the involved side.

Although some evidence has deemed it is acceptable practice, the response in this article emphasizes that the risk of lymphedema is lifelong and they condone taking all risk reduction measures to mitigate against the potential. Therefore it seems prudent to continue avoiding the mastectomy side limb unless circumstances dictate the risk is acceptable, eg. an emergency.

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Medical and health news weekly

Electrical brain stimulation is first approved device for ADHD link

Increasing muscle power even better than strength for prolonging life link

Measles in the US surges to a record number of cases as a result of anti-vaccination quackery link

Rejecting vaccination is a major public health issue as half a million UK children miss measles vaccination link

And quarantine in LA universities because of (yes) measles link

Generic Naloxone nasal spray for opioid overdose approved in US for use by untrained people link

Quitting cigarettes before or in early pregnancy reduces preterm birth link

Soft bedding, prone position, overlay, and wedging still causing infant deaths link

Skipping breakfast again associated with cardiovascular mortality link

Screen time associated with inattention and ADHD symptoms in pre-schoolers link

With the opioid crisis and opioid-phobia, some doctors have misapplied guidelines, cutting off effective pain relief for some patients link

Another infant sleeper recalled link

Caring for the mental health of the medical workforce

The title from the BMA survey into doctors’ and medical students’ mental health applies to all specialties but Anesthesia has ranked in the top in many surveys.

40% reported symptoms of depression, anxiety, burnout, stress, emotional distress or a mental health condition that is impacting on their work/training/study.

27% of respondents reported being diagnosed with a mental health condition at some point in their life.

Doctors work when they know they are unwell and are reluctant to take sick leave.
D

Most participants, if they could avoid it, did not disclose their illness to their educational supervisor or anybody else who might have any influence over their career progression. D

Access to appropriate support was impeded for the interviewees in a number of ways including cultural barriers.G

Returning from sick leave was difficult for a number of respondents. Experiences varied with regards to support from their line managers and occupational health services. 

The paper emphasizes building a supportive culture, enhancing access to support, and encouraging self-support and peer-support.

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Dental Injury & Anesthesia

A retrospective review of dental injuries in Denmark showed fractures to the central maxillary incisors to be the most common injuries, as well as subluxations. Intubation with Mac blade had a higher incidence of injuries but they also occurred with supraglottic airways. Claims were more frequently approved if more than two intubation attempts were used and if the injury was recognized in‐hospital.

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Morphine vs. Hydromorphone in Day Surgery

This study objective was to compare morphine with hydromorphone for achieving satisfactory analgesia with minimal emesis in ambulatory surgery.

There were no differences in the side-effects of severe itching, respiratory depression, or sedation. Patient satisfaction, discharge times, and post-discharge outcomes, including pain and nausea/vomiting over 24 h, were also comparable.

It is believed by some that Hydromorphone has more euphoric effects that could encourage substance misuse.

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Beta-lactam antibiotics in critically ill patients

Guidelines to optimize beta-lactam antibiotics from France provide a detailed insight into their use in ICU. Topics covered include assessing renal function, determining plasma albumin levels, achieving therapeutic plasma concentrations, minimizing toxicity, therapeutic drug monitoring, the potential use of continuous infusions, and their use in renal replacement therapy.

A detailed article in full text –

Full text

Opioid Dose Variability and Opioid Overdose

This study on those on long term opioid therapy found high variability in opioid dose was associated with a greater than 3-fold increased risk of opioid overdose even after controlling for dose.

This occurred even on low dose opioids. Several mechanisms are postulated, including tapering leading to withdrawal effects that precipitated recommencing higher doses, seeking other opioid prescriptions or sources etc.

Individuals with sustained opioid therapy discontinuation (defined as 3 continuous months with 0 mg of morphine equivalents before the index date) were 51% less likely to have experienced an overdose than individuals who had not discontinued opioid therapy

The authors warn that physicians should consider the risks that may be associated with dose variability when designing and implementing new policies to reduce opioid prescribing.

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