Preoxygenation for Intubation in ICU

A post-how analysis of a previous trial compares Preoxygenation strategies for critically ill patients to minimize hypoxia. They compared bag/mask, non-rebreather, non-invasive ventilation, and high flow nasal oxygenation.

While they found that the main determinants of hypoxemia during endotracheal intubation may be related to critical illness severity and to preexisting hypoxemia, the best performer was non-invasive ventilation.

Post hoc analyses are maligned as “data dredging” that are not designed for these secondary results, but they can also extract useful data. This implies further randomized studies should be done to confirm these findings.

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Delays in CPR and Outcome

The basic message of this study is delay in starting CPR, as well as delay in subsequent Defibrillation or Epinephrine administration worsens prognosis. Witnessed, index cases of cardiac arrest from the Get With The Guidelines– Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis.

Some novel nuances include: delay in CPR led to lower survival even if total time to defibrillation or Epinephrine was the same from cardiac arrest. But delays in defibrillation or Epinephrine after CPR initiation also worsened outcome.

5.7% (3,283 of 57,312) of patients did not have instantaneous initiation of CPR upon determination of a pulseless cardiac arrest. There is a need to determine how these figures can be improved.

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Clear Fluid Fasting in Elective Pediatric Anesthesia

The European Society of Anaesthesiology endorses 1 hour clear fluid fasting for elective pediatric anesthesia. It joins previous consensus statements from the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L’Association Des Anesthésistes‐Réanimateurs Pédiatriques d’Expression Française ( link ).

Unless, as always, there is a clear contraindication!

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Blood Pressure after abdominal surgery

Blood pressure, especially hypotension, has been linked to myocardial and renal injury during and after surgery. This study used a continuous monitoring system ViSi Mobile.

The striking findings were that, in the first 48 hours, postoperative hypotension and hypertension were common, prolonged, profound, and largely undetected by routine vital-sign assessments in a cohort of adults recovering from abdominal surgery. Some significant figures included MAP < 65 and even > 130mm Hg in sizeable percentages.

Frequent or continuous blood pressure monitoring may detect hemodynamic perturbations more effectively and potentially facilitate treatment, but randomized studies are needed to establish how risk may be mitigated and outcomes determined and improved.

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Carbetocin in Elective Cesarean Section

Maternal postpartum hemorrhage is a common complication and indeed accounts for the highest fraction of global maternal mortality (35%).

Routine uterotonics are recommended after delivery as they significantly reduce hemorrhage. Oxytocin is well known, but SOGC recommended a single 100 μg i.v. bolus dose of carbetocin over 1 min (in lieu of an oxytocin infusion) as the uterotonic agent of choice to prevent PPH after elective caesarean delivery; the rationale is that its duration of action is 4 to 7 times that of Oxytocin. This dose comes from manufacturers recommendations.

This randomized non-inferiority design study tested 20mcg vs. 100mcg Carbetocin in elective Cesarean under Spinal Anesthesia.

Uterine tone at 2mins did not meet criteria but 20mcg was non-inferior to 100mcg at 5 mins in terms of uterine tone and hemorrhage as well as the need for further uterotonics.

The numerical rating score for uterine tone may be operator dependent and subjective but the authors suggest further studies to assess the clinical significance of their findings, as all other side effects were basically similar. The study may be underpowered in terms of numbers.

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Obstructive Sleep Apnea and Ventilatory Depression

It has become axiomatic to state that patients with obstructive sleep apnea (OSA) are more sensitive to opioid induced ventilator]y depression. This small controlled study used Remifentanil infusions to test this theory. They found that obstructive sleep apnea status, apnea/hypopnea events per hour of sleep, or minimum nocturnal oxygen saturation measured by pulse oximetry did not influence the sensitivity to remifentanil-induced ventilatory depression in awake patients receiving a remifentanil infusion of 0.2 μg · kg–1 of ideal body weight per minute.

While this study was on awake patients using a specific ultrashort acting opioid, clinical practice is still likely to be guided by an abundance of caution in administering opioids to OSA patients, especially in the perioperative period, where sedation, sleep, and anesthesia may compound the issue.

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Medical and Health News Weekly

The risk of infective endocarditis related to injection drug use is increasing and is temporally associated with increasing prescriptions for hydromorphone link

For infants at high risk for allergic disease, it is now recommended that commonly allergenic solids be introduced at around 6 months of age, but not before 4 months of age link

Washington State declares emergency – measles outbreak. You’ll recall we all used to be vaccinated against measles before quackery took precedence over science link

There may be a cognitive benefit to reducing blood pressure, although the link to dementia not clear link

Please avoid kissing your hedgehog who could have a bad Salmonella link

Excessive toddler screen time can impinge on children’s ability to develop optimally link

E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support link

Eat breakfast but it may not help you to lose weight as often suggested link

Stethoscopes teeming with bacterial DNA! link

Dietary supplements for brain health are a multi billion dollar industry based on pseudoscience and dodgy predatory journals link

Injuries associated with standing electric scooter use are a new phenomenon and vary in severity link

Being absent from school too often, excused or not, can put a child’s academic achievement—and future health—at risk link

Surviving Sepsis Update 2019

Another update on the Surviving Sepsis Campaign. Stemming from experts’ concerns about excessive fluid administration and rushing the diagnosis, the update acknowledges more time may be needed to establish a definitive diagnosis, while still stressing the urgency of sepsis treatment. And it also advises vasopressors may be started concurrently with fluid for hypotension:

Surviving Sepsis Campaign Hour-1 Bundle of Care Elements:

  • Measure lactate level*  
  • Obtain blood cultures before administering antibiotics.
  • Administer broad-spectrum antibiotics.
  • Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 ​mmol/L.
  • Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.

* Remeasure lactate if initial lactate is elevated (> 2 mmol/L).

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Immunonutrition for ARDS

Much expert opinion has debated the potential value of immunonutrition in critical illness. This Cochrane review was a meta‐analysis of 10 studies of varying quality examining effects of omega‐3 fatty acids and/or antioxidants in adults with ARDS.

The conclusion showed the intervention may produce little or no difference in all‐cause mortality. The low quality evidence could not lead to conclusion on benefits in terms of oxygenation, ICU or ventilation duration, or other adverse effects.

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