Quite apart from that fungal contaminated fiasco ( nejm ) the evidence for steroids has been weak and short lived benefit at most, and this study calls for caution also in those at risk for osteoporotic fractures like post menopausal women
Breathing exercises and personal education pre-op rather than booklets reduced post operative pulmonary complications. More studies needed as mortality effect not clearly demonstrated bmj
In other news, myocardial infarction up sixfold in the week after respiratory infection, especially influenza nejm
Is your patient really unconscious?
A plea to monitor the brain as much as the heart, circulation, ventilation and oxygenation; both awareness and delirium/POCD potentially impacted. Also a review of current brain monitors, including Bispectral Index.
Some of the limitations and disappointing trials summarized here Link
The quick SOFA should alert us to increased mortality risk. qSOFA: altered mental status, respiratory rate >22 and systolic BP <100. Adding Lactate can increase sensitivity. qSOFA doesn’t define sepsis, but should prompt a thorough evaluation and full SOFA score ( sofa calc ).
“Sepsis 3 Consensus”: Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection; septic shock requires vasopressors to maintain MAP 65mm, lactate>2 in the absence of hypovolemia.
The SIRS term is gone from sepsis in favour of qSOFA and severe sepsis is now just sepsis.
A clear summary qsofa link
So don’t abandon the full SOFA yet sofa jama
An interesting view of different institutions’ protocols on enhanced recovery. Common elements are pre-op education, exercise and respiratory training, clear fluid carbohydrate loading with 2 hour clear fluid fast, no bowel prep in some cases, no premedication, Alvimopan for bowel motility unless contraindicated, multimodal analgesia with frequent use of epidural or spinal morphine, lidocaine infusion where no epidural, two antiemetics, restrictive or goal directed fluids, normothermia, normoglycemia, early fluids advancing to diet one day post-op with ambulation amd continued antiemetics, early discontinuation of fluids, early removal of catheters and drains.
But if it’s hard to implement, you’re probably not alone JAMA link
This BJA study makes the case. And no need to give up the Mac blade for direct view with the C-MAC.
GlideScope also offers Spectrum MAC-style blades for direct vision e.g. where blood occludes the camera image. Some concerns now exist in airway groups as to the loss of awake flexible bronchoscope skills, once the go-to anticipated difficult intubation recommendation.
“Historically, implementation of cell salvage in obstetrics has been limited by concerns regarding maternal alloimmunization requiring additional Rho(D) immune globulin administration in Rh-negative mothers and a concern for amniotic fluid embolism, although there has only been one case report suggesting a potential link between amniotic fluid embolism after cell salvage”.
This study finds it cost effective only in high risk cases Anesthesiology link