Erector Spinae Block for Rib Fractures

Another study uses an arguably simpler block than paravertebral for rib fractures. It quantified incentive spirometry pre and post block.

The majority had continuous catheters and the study found that erector spinae plane blocks were associated with improved inspiratory capacity and analgesic outcomes following rib fracture, without haemodynamic instability.

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Rib Fractures and Paravertebral Catheters

This retrospective study over four years showed almost half of patients with rib fractures had ultrasound guided paravertebral catheters inserted by the fourth year. Only minor complications were reported. The conclusion was that “paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.”

They seem clearly useful as part of an opioid free or sparing approach to rib fractures.

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Traumatic Brain Injury and Goal Directed Therapy

“The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes”

This was a planned secondary analysis and the physiologic transgressions referenced include deviations like anemia (Hb <8), hyperglycaemia, low mean (< 65) or systolic blood pressure, raised INR > 1.4, and raised ICP > 20

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Medical and Health News Weekly

Only 5% of teens get enough sleep link

Obesity-related cancers on the rise in young people link

Netflix gives Gwyeth Paltrow a docuseries with her GOOP brand. You might also prefer to be guided by medical and scientific expertise link

Counterfeit Xanax linked to many deaths link

Surgery not recommended for subacromial pain (rotator cuff disease) link

Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection link

Compounded pain creams are no better than placebo creams link

Tobacco-naive youths who initiate e-cigarettes may be at greater risk of subsequently initiating cigarette smoking link

European measles cases highest in decade link

EEG guided Anesthesia and Delirium

Some retrospective evidence has lent hope to the attractive notion that reducing anesthesia depth by titrating anesthesia to EEG could also reduce delirium in postoperative elderly patients.

In this study, the primary outcome was incident delirium during postoperative days 1 through 5. While anesthesia agent use was less in the guided group, this randomized study found: These findings do not support the use of electroencephalography-guided anesthetic administration for the prevention of postoperative delirium among older adults undergoing major surgery.

There was no difference in hypotension or awareness under anesthesia, other postulated related outcomes. Lower mortality at 30 days did occur in the EEG guided group, but the significance of this secondary outcome is unclear from this study.

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Pressure Controlled Ventilation for Pediatric Facemask

From an early view study in Pediatric Anesthesia: At an inspiratory pressure of 13 cmH2O, pressure‐controlled ventilation may be more effective than manual ventilation in preventing gastric insufflation while providing stable ventilation in children.

This is also a useful maneuver to free both hands to maintain a patent airway without needing another staff member to squeeze the breathing bag, and could usefully be further studied in adults in difficult mask-ventilation scenarios. Modern anesthesia machines provide such modes as Pressure Control and Pressure Control-Volume Guaranteed.

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Difficult Intubation Prediction

Anesthesiologists take an intuitive eyeball approach to anticipating difficult intubations, but many formal scores and assessment tools of varying sensitivity and specificity exist, like the Mallampati or Wilson scores. This full text JAMA review looks at some of these in predicting difficult intubation.

The best predictors were an inability to bite the upper lip with the lower incisors, a short hyomental distance, retrognathia, or a combination of findings based on the Wilson score.

The inability to bite the upper lip with the lower teeth was the best predictor.

A good full text review at this link

Failed Laryngoscopy and Intubation

The full text review is gated for non subscribers but provides a thoughtful reflection on terminology, preparation, skill acquisition, VortexApproach , SGAs, eFONA etc.

Some practical advice is also offered on topics such as apneic nasal oxygenation to prolong time to desaturation, bougie assisted supraglottic airways, and the steps in emergency front of neck airway (eFONA), reviewed elsewhere in this blog – blog link

Optimimizing using ‘best effort” in each part is emphasized: facemask, supraglottic airway, and intubation, leaning on the philosophy of the Vortex Approach ( link )

Journal link

Anesthesia in MRI Units

A full text guidance from Anaesthesia for anesthesia providers in MRI units. The focus is on having leaders, and properly trained and experienced staff familiar with the challenges of the MRI unit. Detailed descriptions of anesthesia administration and monitoring are provided along with discussion of devices and their classification as safe, conditional or unsafe.

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Summary Infographic

Peripartum Cardiomyopathy

Of interest to obstetric anesthesiologists, a BMJ current review of this rare but serious dilated cardiomyopathy with systolic dysfunction that presents in late pregnancy or, more commonly, the early postpartum period.

Risk factors include black ancestry, pre-eclampsia, advanced maternal age, and multiple gestation pregnancy. Half recover but many more are left with chronic disease and a minority require mechanical support and/or transplantation.

Features are common to heart failure, and also include arrhythmias and thromboembolism (anticoagulation for which will impact neuraxial anesthesia). General treatment measures are discussed and potential specific treatments, including Bromocriptine for Prolactin inhibition, a postulated mechanism in etiology.

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