Anesthesia & Co-existing Disease

Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant

Many differing regimes have been recommended by different organizations as well as those using different direct oral anticoagulants (DOACs) based on their half life and renal function.

A simple regime was employed, largely amounting to interruption of DOACs 1 day before low bleeding procedures or 2 days before high bleeding risk procedures, with an adjustment for moderate renal dysfunction for Dabigatran. Resumption occurred in 1 day with low bleeding risk and 2 – 3 days with higher bleeding risk.

Conclusion: “A simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of major bleeding and arterial thromboembolism.“

How this meshes with regional or neuraxial anesthesia guidelines as in ASRA is open to further discussion.

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Association between complications and death within 30 days after noncardiac surgery

It is rare to die in the Operating Room.

This prospective study looked at the rate and cause of death after non-cardiac surgery.

“Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality”

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Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy

The decline is Succinylcholine use has been expedited by the arrival of Sugammadex. Succinylcholine is often still preferred where the risk of aspiration is deemed higher.

This study compared rapid sequence induction (RSI) with modified rapid sequence induction (mRSI) in infants.

The conclusion found mRSI acceptable practice: “In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.”

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Mannitol in Critical Care

Mannitol has a long history of use to decrease intracranial pressure in neurosurgery and traumatic brain injury but it’s effect on long term outcome is still uncertain.

This free full text review – a meta-analysis and systematic review – surveys its history and usage. Its conclusion is essentially:

“Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.”

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Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis

This retrospective study surveyed general vs. spinal anesthesia for infants with pyloric stenosis. While it may not be in the comfort zone for some practitioners, it was shown that it was a viable alternative to general anesthesia, reducing the respiratory morbidity associated with the latter, significantly reducing apneic episodes and desaturation.

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Stillbirth linked to more childbirth complications

A commentary on a journal study showing life-threatening delivery complications are more than four times as common during and after a stillbirth than a live birth. Some of these complications are more than 10 times as likely with stillbirths, per this Stanford study.

Complications included sepsis and shock, renal failure and cardiac problems. Certain causes if stillbirth like infection or hypertensive diseases were strongly linked to delivery complications for the mother.

This highlights another area to continuously improve maternal care, California also previously making important quality strides in maternal care improvement.

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Postoperative Delirium and Long-term Decline in Activities of Daily Living

Delirium occurs all too commonly in the elderly after surgery, in a quarter of elderly patients after major elective and urgent major orthopedic surgery in this study.

The deleterious impact of delirium is well documented by now, although some studies do not prove causation versus association, but the conclusion adds more to this evidence:

“Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.”

The follow up occurred between 24 and 36 months after anesthesia and surgery.

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Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block

Hemi-diaphragmatic paralysis from Phrenic Nerve Block is a frequent accompaniment to Interscalene Brachial Plexus Block that may be detrimental to those with compromised respiratory function.

This randomized trial compared the more selective targeting of the nerves using the more novel Superior Trunk Block employing ultrasound.

Conclusions: “Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.”

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