SGLT Inhibitors and Diabetic Ketoacidosis

The popularity of SGLT Inhibitors has increased with purported cardiovascular and renal benefits. Issues have arisen however and this consensus addresses the reported cases of normoglycemic diabetic ketoacidosis.

Pertinent to perioperative care, “SGLT inhibitors should be withheld or discontinued prior to any medical procedure (ideally for 3 days), particularly if the patient will be reducing food intake or will not be allowed to eat or drink for some time before and after the procedure.”

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Early Neuromuscular Blockade in ARDS

The fashion that has returned for early neuromuscular block in ARDS was tested in this study.

“Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets”.

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Tramadol and Persistent Opioid Use

Faced with the opioid epidemic, many have turned to postoperative use of Tramadol in the belief it has less misuse potential.

This observational study finds however that: “People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids”.

They advocate reclassifying Tramadol and urge caution in its prescription.

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Intraoperative Seizures During Elective Craniotomy

This retrospective study found that the incidence of intraoperative seizures during elective craniotomy with evoked potential monitoring is low. 

The overall incidence of intraoperative seizures was 2.3%. Independent risk factors for intraoperative seizures were seizure history, diagnosis of intracranial tumor, and temporal craniotomy. 

Intraoperative prophylactic anticonvulsant use was protective.

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Post Dural Puncture Headache Treatment

A new guideline from the Obstetric Anaesthetists Association underlines how little evidence is really available to guide management of post dural puncture headache. Epidural Blood Patch remains the best treatment but in general is more effective after 48 hours. Some relief occurs in up to 80%, and complete resolution of pain in about a third. It may need repeating. 20mL blood is suggested or less if back pain develops.

There is insufficient evidence on a whole host of suggested treatments – steroids, gabapentinoids, ACTH, caffeine, triptans, theophylline, neostigmine and atropine, acupuncture, various nerve blocks, and epidural crystalloid.

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Neuraxial Anesthesia-Delivery time interval

Traditionally one of the more critically identified time frames after spinal anesthesia for Cesarean is the uterine incision to delivery time, and this is confirmed in this study.

After neuraxial anesthesia, uterine hypoperfusion from hypotension and maternal obesity may compromise the fetus. This study shows a direct correlation between increasing delay before delivery and decreasing umbilical artery pH.

“Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.”

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Opioid Sparing in Pediatric Adenotonsillectomy

This QI project identified an opioid sparing anesthesia approach for pediatric tonsillectomy and adenotonsillectomy that moved away from morphine and acetaminophen, though Dexmedetomidine plus Ibuprofen, and finally on to the most effective regime consisting of Dexmedetomidine plus Ketorolac.

The study highlights both the move away from opioid based anesthesia as well as the increasing use of Intraoperative Dexmedetomidine.

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Propofol and Food Allergies

There is some disquiet about using Propofol in those with allergies. This was a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia.

In 9 out of 10 meeting allergic reaction criteria, valid non‐allergic explanations for the clinical symptoms were found.

The authors conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

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Trans-Nasal Evaporative Intra-arrest Cooling

Much of the earlier enthusiasm for therapeutic hypothermia has been tempered with disappointing trial results. This study examined cooling of the brain initiated during cardiopulmonary resuscitation and its impact on survival with good neurologic outcome in patients with out-of-hospital cardiac arrest.

Trans-nasal evaporative intra-arrest cooling did not result in a statistically significant improvement in survival with good neurologic outcome.

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