Intermittent Lumbar Plexus Block vs. Continuous

A clear trend towards programmed intermittent bolus rather than continuous infusion has emerged in epidural analgesia in labor. Other regional analgesia pain blocks have found the same.

This study using lumber plexus block in total hip arthroplasty again finds intermittent rather than continuous infusion led to lower opioid rescue and more consistently maintained sensory block.

The regime was: continuous infusion group 6 mL/hour continuous infusion of levobupivacaine 0.125%, and intermittent infusion group 12 mL of levobupivacaine 0.125% bolus delivered every 2 hours.

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Medical and Health News Weekly

First HIV-HIV organ transplant link

Numerous non-surgical brain stimulation techniques are alternative or add-on treatments for adults with major depressive episodes link

The latest craze with zero evidence, and potential harm – intravenous vitamins link

China to tighten regulation of Fentanyl-like substances link

FDA investigating potential vaping link to seizures in young people link

Nova Scotia to become first in North America with ‘presumed consent’ to organ donation unless an opt-out link

Poor diet killing more than cigarettes. 1 in 5 deaths from diets too low in whole grains, fruit, nuts, seeds and vegetable intake and too high in salt link

Dozens of women sue California hospital for secretly recording their surgeries link

New York lawsuit highlights the growing promotion of unproven stem cell therapies link

Sales of Biocell textured breast implants, linked to rare lymphoma, could soon be suspended by Health Canada link

HPV vaccine has almost wiped out cervical pre-cancer in Scotland. Yes, vaccines work and save lives link

Yet another study shows no benefit from light drinking – increased stroke risk from a drink a day link

Airway pressure release ventilation

Airway pressure release ventilation (APRV) arrived with much hope of a novel strategy to minimize lung injury with its ‘open lung’ concept.

This systematic review and meta-analysis surveyed the literature. They found a higher number of ventilator-free days at 28 day and a lower hospital mortality in acute hypoxemic patients treated with APRV than conventional ventilation, without any negative hemodynamic impact or higher risk of barotrauma.

They caution however that the evidence is low quality with some heterogeneity and further randomized trials are needed before APRV can be recommended as superior to conventional strategies.

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Intra-operative high inspired oxygen

Many studies have suggested high oxygen concentrations intraoperatively are linked to increased respiratory complications. The WHO has come in for criticism for its recommendation to use 80% O2 to decrease wound infection. Guidelines for oxygen therapy have stressed using SpO2 of 95% as a general goal with the minimum FiO2 in many conditions including myocardial infarction etc.

This post hoc subanalysis in colorectal surgery concluded “Intra-operative hyperoxia did not change the postoperative SpO2/FiO2 ratio or the risk for pulmonary complications. Clinicians should not refrain from using hyperoxia for fear of provoking respiratory complications”.

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Accompanying editorial discusses complexity of unaccounted variables like tidal volume, PEEP, and recruitment maneuvers editorial

Dysphagia in ICU

A full text article reviews the often overlooked issue of dysphagia in the ICU.

Dysphagia is associated with an increased risk of aspiration and aspiration-induced pneumonia, delayed resumption of oral intake/malnutrition, decreased quality of life, prolonged ICU and hospital length of stay, and increased morbidity and mortality.

Post-Extubation dysphagia occurred in the authors’ study in c. 18%, and persisted in 60% of post-extubation ICU cases at hospital discharge, but other studies have shown much higher incidences.

Potential causes include direct trauma from tubes, neuromyopathy resulting in muscular weakness, diminished laryngeal sensory function, an impaired sensorium, reflecting a more centrally located problem, gastroesophageal reflux, and dyssynchronous breathing and swallowing.

The most consistent risk factor is probably duration of intubation, but factors such as trans-esophageal echocardiogram have been implicated.

Numerous bedside swallowing assessment tests are discussed as well as the more accurate flexible endoscopic evaluation of swallowing.

Management strategies are discussed like training, maneuvers, food textures , as well as the more recent pharyngeal electrical stimulation.

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Oxygen Saturation Index Vs. Oxygenation Index in Neonates

Beyond the PaO2/FiO2 ratio in hypoxic respiratory failure, the Oxygenation Index (OI) is used in neonates, with 15/25/40 representing mild, moderate and severe illness. This retrospective study compared invasive with non-invasive measures of severity of respiratory failure.

OI = MAP × Fio2 × 100 / Pao2, where MAP indicates mean airway pressure.

Oxygen Saturation Index (OSI), a non-invasive counterpart is defined as OSI = MAP × Fio2 × 100 / Spo2

OI and OSI showed a strong correlation. Derived OI from OSI was in good agreement and strongly predictive of clinically relevant OI cutoffs from 5 to 25.

More studies in different disease severity are needed but OSI may provide a useful non-invasive alternative to OI in this setting.

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Mortality Reduction in Military Trauma

Much of the early evidence in trauma management has been gleaned from military combat experience in recent years.

While many confounding variables exist in such a retrospective study, the conclusions appear in step with current trauma management (recent link )

The analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction.

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Perioperative Opioids in Children Guidelines

The Society for Pediatric Anesthesiology issues guidelines for perioperative opioid use. Many of the recommendations are not that different to adults in terms of assessing pain, safety/monitoring, patient controlled analgesia, outpatient analgesia, side effects, adjunctive agents/regional anesthesia…

Caution is advised with the potential seizure activity of both Meperidine (Pethidine) and Tramadol, and Codeine is advised against once again due to unpredictable metabolism.

Free PDF link

Norepinephrine vs. Phenylephrine in Cesarean

Norepinephrine has recently been increasingly studied for prophylaxis against hypotension during Cesarean Section under spinal anesthesia.

Phenylephrine has been shown to ameliorate hypotension and nausea/vomiting when given as a prophylactic infusion following spinal anesthesia.

This study compared the two agents and found Norepinephrine infusion effective and associated with less reactive hypertension and bradycardia. Neonatal outcomes were the same.

Norepinephrine rates were started at 0.05 mcg/Kg/min and Phenylephrine at 0.75 mcg/Kg/min.

This adds to growing evidence for Norepinephrine as an option in this scenario.

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