Medical & Health News Weekly

Measles as the comeback kid continues and spurs mandatory vaccination in NY link

The measles and anti-vaxxers issue needs concerted action link

Don’t waste your money on ineffective vitamins and supplements in lieu of a healthy diet link

Bawa Garba to be allowed return to practice under supervision link

Too much of a good thing – or buying into unfounded hype – kidney failure from excessive Vitamin D link

Another lawsuit in the opioid saga, this time against Indivior for its Suboxone Film marketing link

Can AC electrical trans-cranial brain stimulation boost memory? link

American Academy of Pediatrics and others have now succeeded in getting Fisher-Price baby sleeper recalled due to links to 32 infant deaths link

Concerns are growing globally about drug resistant ‘superbug’ fungus Candida auris link

Laws, prescribing limits lead to dramatic opioid prescription fall but FDA warns on need to taper and not stop abruptly link

Stress related disorders are robustly associated with multiple types of cardiovascular disease link

Ebola in Congo not a global public health emergency, says WHO. Not yet anyway… link

Guidelines for day‐case surgery 2019

Day case surgery continues to proliferate and is intended to be the method of choice in the majority of surgeries. It’s self-evident meaning should not be confused with 23-hour stay in the US.

This updated free paper from the Association of Anaesthetists in Britain/Ireland provides an excellent overview of the practice of ambulatory surgery.

Topics include the need for organization, leadership and governance involving physicians and non-physicians in pre-admission clinics, and selection of patients. Discussion around specific issues like obesity and obstructive sleep apnea occurs. Spinal anesthesia need not be a barrier. ‘Fitness for a procedure should relate to the patient’s functional status as determined at pre‐anaesthetic assessment, and not by ASA physical status, age or body mass index’.

Multimodal analgesia techniques including regional nerve blocks should be the norm.

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Lung Resection, Anesthetic Technique and ICU Admission

This retrospective study examined Total Intravenous Anesthesia (TIVA), volatile inhalational anesthesia, and analgesic techniques of epidural or paravertebral block. Lung resection was the specific focus.

The aim was to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission – defined as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy.

It was found that patients having TIVA or epidurals were less likely to have an unplanned admission to intensive care.

Mortality and length of stay was higher in those needing unplanned ICU admission.

The study discusses possible mechanisms for these findings but emphasizes that prospective randomized trials are needed to prove causation.

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Rib Fracture Analgesia

Rib fractures cause significant impairment of respiratory function and are often accompanied by severe pain. Two studies add to our knowledge.

The first used ultrasound guided paravertebral block. While they couldn’t definitely prove any mortality benefit, they found it safe, effective and with low complication rate.

The second used potentially easier Erector Spinae plane blocks, which were associated with improved inspiratory capacity and analgesic outcomes following rib fracture, without haemodynamic instability. Opioid consumption was not reduced however.

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Percutaneous peripheral nerve stimulation for post-amputation pain

A majority of patients have been reported to experience post amputation neuropathic limb pain, with twin components of residual limb pain, and phantom limb pain. Its refractory nature has spurred a variety of physical, psychological, opioid and non-opioid therapies.

With the arrival of improved percutaneous ultrasound-guided fine-wire coiled peripheral nerve stimulation (PNS) leads in proximity to the sciatic and femoral nerves, this randomized study reported significant pain relief and improved disability in patients with chronic neuropathic postamputation pain.

The reversible procedure involved 8 weeks stimulation, but longer term improvements persisted. Further follow-up and study is ongoing for this promising intervention in an often intractable condition.

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Preoperative predictors of poor acute postoperative pain control

A systematic review and meta-analysis sought to identify preoperative factors that could predict poor postoperative pain control. Some new links were found, and others that might have been suspected did not show association.

In brief, factors predicting poor postoperative pain control were: younger age, female sex, smoking, history of depressive or anxiety symptoms, sleep difficulties, higher BMI, presence of preoperative pain, and use of preoperative analgesia.

Sleep difficulty and depression showed the strongest association.

Pain catastrophizing, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control.

Hopefully outcomes can be improved by individualized targeting of pain-predictive factors.

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Frailty and Geriatric Trauma

Frailty in the elderly is now well established as a marker for adverse outcome. This retrospective study implemented an interdisciplinary care pathway for older, frail trauma patients, which included early ambulation, bowel/pain regimens, non-pharmacological delirium prevention, nutrition/physical therapy consults, and geriatrics assessments.

A significant decrease in their delirium and 30-day readmission risk was found.

The study highlights again the importance of non-pharmacological and proactive approaches to delirium and other potential outcome improvements in this vulnerable population.

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ROTEM®‐guided algorithm in treatment of coagulopathy in obstetric haemorrhage

Point of Care coagulation assessments like ROTEM and TEG have been available for many years but data on outcome has been slower to emerge.

Hemorrhage management using traditional PT and PTT is a blunt instrument and has a slow laboratory turnaround time. Obstetric hemorrhage is different to trauma.

This is an obstetric hemorrhage report on 4 years of observational data from a tertiary care center using an algorithm based on FibTEM A5 assessment of hypofibrinogenemia. It resulted in a reduction in the number of units transfused and volume given, with less circulatory overload.

The authors note that coagulopathy is not observed in all women who suffer obstetric haemorrhage and cannot be predicted solely by blood loss, and also that women with placental abruption exhibited more severe coagulopathy and required higher doses of fibrinogen concentrate than women who bled due to other causes.

The results encourage point of care rather than formulaic blood product use to individualize cosgulopathy treatment.

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Intra‐operative analgesia: Remifentanil vs. Dexmedetomidine

The ultrashort duration of Remifentanil seemed ideal for anesthesia until the drawbacks of opioid-induced hyperalgesia and acute opioid tolerance were described.

Dexmedetomidine has become part of opioid sparing (or free) anesthesia and this meta-analysis compared the two.

Pain scores at rest at two postoperative hours were lower in the dexmedetomidine group, as well as at 24 hours in the secondary outcome. Hypotension, shivering and postoperative nausea and vomiting were at least twice as frequent in patients who received remifentanil.

Time to analgesia request was longer, and use of postoperative morphine and rescue analgesia were less, with dexmedetomidine; episodes of bradycardia were similar between groups.

Dexmedetomidine is clearly a useful option or adjunct to anesthesia. Somnolence may limit its use in ambulatory surgery, except in low doses.

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