In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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Suicide in Anesthesiologists

Light is shed upon this once taboo subject in this Association of Anaesthetists survey. The entire spectrum of stress, depression, burnout, sleep deprivation, etc. is now a pressing issue in healthcare professionals. Anesthesiologists have ready access to potent medications, posing addiction risks as well as intentional or accidental fatal overdose.

This survey looked at experiences of colleague suicide as well as the support schemes in place, and awareness of same.

Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads. Deficiencies were noted in the support available and in the way the deaths were handled.

The authors summarize their paper: “emphasizes the need for continued work in promoting discussion, awareness and support of mental health issues, including work‐related stress and alcohol/drug misuse, throughout healthcare systems and anaesthetic departments. We hope that the Association of Anaesthetists guidance, currently in preparation, will provide a useful resource for individuals and departments in this area.”

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Unprofessional Behavior by Surgeons and Surgical Complications

Unprofessional or what is known as disruptive behaviour has been shown to be rife in hospitals. This retrospective study tested the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications.

The conclusion: “Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. ”

The authors point out that “optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.”

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Blood Purification and Mortality in Sepsis and Septic Shock

A systemic review and meta-analysis of a variety of modalities such as hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique were compared to conventional therapy in adult patients with sepsis and septic shock.

“Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock.”

Clearly the evidence for these “blood purification” strategies will require further randomized higher quality trials before they can be routinely recommended.

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis

This latest malpractice analysis still leaves concern for the outcomes in difficult tracheal intubation, showing outcomes still remain poor. Death is still a not uncommon occurrence.

The authors summarize: “Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.”

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Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

The latest newcomer to regional anesthesia in breast cancer surgery is the PEC-2 Block.

This review and meta-analysis shows essentially an equivalence to Paravertebral Block.

“Petoralis-II blocks were noninferior to paravertebral blocks in reducing pain intensity and morphine consumption for the first 24 h after surgery and both were superior to systemic analgesia alone”.

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Association of Opioid Overdose With Opioid Prescriptions to Family Members

It is known that opioid use often stems from family or friend prescriptions.

“In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions”.

“Prior opioid dispensing to family members was associated with 2.89-fold higher odds of individual overdose, which persisted in young children and increased with greater quantities of opioid medications dispensed to family members.”

Increased education as to the risks, safe storage of opioids, and availability of opioid antagonists is suggested.

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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Ketamine Infusions for Chronic Pain

A series of Ketamine infusion treatments for chronic pain have sprouted “Ketamine Clinics” globally but the longer outcome has not clearly been defined. Ketamine as an opioid-avoiding modality has often spurred the movement.

This review and meta-analysis summarizes the data, finding benefit in the short term (a few weeks) with less confidence on longer term pain relief, as well as higher incidences of nausea and psychotomimetic side effects:

“Evidence suggests that IV ketamine provides significant short-term analgesic benefit in patients with refractory chronic pain, with some evidence of a dose–response relationship. Larger, multicenter studies with longer follow-ups are needed to better select patients and determine the optimal treatment protocol.”

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Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.

They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”

It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”

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