Month: July 2019

International consensus statement on the use of uterotonic agents during caesarean section

This statement updates use of uterotonic agents. Traditionally Oxytocin has been used in higher then needed doses and this statement reiterates current expert opinion on the use of smaller titrated doses in most situations, especially in elective Cesarean.

They discuss the increasing use of Carbetocin as an alternative, which has the advantage of a longer half life thereby obviating the need for an infusion. Side effects are similar.

Second line agents are discussed also.

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Peripheral Nerve Blocks for Ambulatory Shoulder Surgery

Nerve blocks are now almost universal during shoulder surgery for their superior analgesia. This study reviewed post-discharge outcomes.

A decrease in unplanned admissions was found. There was no improvement in other postoperative outcomes such as emergency department visits, readmissions, mortality, or practical costs.

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Cesarean Delivery and Neuraxial Opioids

This consensus statement from SOAP specifically addresses the use of neuraxial Morphine in Cesarean delivery and looks st dosing, safety and monitoring.

It clearly favours the use of neuraxial Morphine as part of a multimodal analgesia regime and how the benefits and risks may be addressed using appropriate monitoring.

It should be reviewed by all who provide Obstetric anesthesia.

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Consensus Statement on Persistent Postoperative Opioid Use

This statement looked at the definition, incidence and risk factors for persistent postoperative opioid use and how it might be dealt with.

“Patient characteristics associated with an increased risk of persistent postoperative opioid use included preoperative opioid use, depression, substance use disorder, preoperative pain conditions, and smoking.”

They discuss in the free full text how health policy may help to curtail persistent opioid use.

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Mortality and major morbidity after hip fracture surgery and Anesthesia

This retrospective analysis doesn’t prove causality but findings were in keeping with prior work.

Spinal anesthesia was weakly associated with a lower 90-day mortality following hip fracture surgery, and also associated with improved morbidity evidenced by a lower rate of pulmonary embolism and major blood loss and a shorter hospital length of stay.

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Mannitol in Critical Care

Mannitol has a long history of use to decrease intracranial pressure in neurosurgery and traumatic brain injury but it’s effect on long term outcome is still uncertain.

This free full text review – a meta-analysis and systematic review – surveys its history and usage. Its conclusion is essentially:

“Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.”

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

This study assessed the value of commonly used predictors of fitness for extubation in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Their conclusions:

“Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.”

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Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis

This retrospective study surveyed general vs. spinal anesthesia for infants with pyloric stenosis. While it may not be in the comfort zone for some practitioners, it was shown that it was a viable alternative to general anesthesia, reducing the respiratory morbidity associated with the latter, significantly reducing apneic episodes and desaturation.

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Music versus midazolam during preoperative nerve block placements

The essential conclusion in this study was the equivalence between music played through noise cancelling headphones and Midazolam.

While previous evidence has suggested the utility of music for awake patients, it should be noted that physician satisfaction was higher than patient satisfaction. And both judged communication to be more impaired in the music group.

Nonetheless sedation has gone s little out of fashion in both anesthesia and ICU with links to delirium in many studies in the elderly and substitution with music may be worth considering.

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Stillbirth linked to more childbirth complications

A commentary on a journal study showing life-threatening delivery complications are more than four times as common during and after a stillbirth than a live birth. Some of these complications are more than 10 times as likely with stillbirths, per this Stanford study.

Complications included sepsis and shock, renal failure and cardiac problems. Certain causes if stillbirth like infection or hypertensive diseases were strongly linked to delivery complications for the mother.

This highlights another area to continuously improve maternal care, California also previously making important quality strides in maternal care improvement.

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