Sepsis

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

But (and there always is a but) many dispute the accuracy of qSOFA. As in this study Anaesthesia article where SOFA and NEWS ( news score ) outperformed.

So don’t abandon the full SOFA yet sofa jama

Enhanced Recovery after Surgery (ERAS)

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.

ASER protocols

But if it’s hard to implement, you’re probably not alone JAMA link

 

Universal Videolaryngoscopy?

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.

BJA study

 

Cell Salvage for Obstetric Hemorrhage

“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