Anesthesia Management

Propofol and Cancer Survival

Speculative and theoretical evidence has suggested Propofol anesthesia has less effect on immune function and cancer spread and this study finds remarkable evidence to support that Propofol based TIVA (total intravenous anesthesia) in colon cancer surgery is associated with better survival compared to Desflurane anesthesia, 33% vs 15%.

Several caveats include a retrospective study design, TNM staging, lack of blood use data and potential selection biases. Nonetheless this hypothesis needs more study and it is not unreasonable to use TIVA for cancer surgery taking this and other circumstantial evidence into account.

link

 

High Flow Nasal Oxygen & Length of Stay

The enthusiasm for high flow nasal oxygen continues unabated. This study was on high‐risk patients with pre‐existing lung disease (COPD, asthma, recent lower respiratory tract infection), heavy smokers or morbidly obese patients (body mass index (BMI) ≥ 35 kg.m−2), who were expected to stay longer in ICU and hospital due to increased respiratory complications after cardiac surgery.

When compared with standard oxygen therapy care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. The authors recommend routine use of high‐flow nasal oxygen after tracheal extubation in this cohort of patients and further testing of their hypothesis in large multi‐centre randomised trials.

link

 

Post-op Opioid Consumption

It would appear that opioid prescription post operatively is still excessive after abdominal surgery. “Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion”.  This study shows just how little opioid amounts are needed on average.

link

 

Cardiac Output Based Fluids for Kidney Transplant

A small study on fluids for deceased donor kidney transplantation compared esophageal Doppler based stroke volume optimization with conventional clinical practice. Complications and delayed graft failure were no different and the primary endpoint – amount of fluid given – did not significantly differ. Pending larger studies this does not support cardiac output based fluid administration during kidney transplantation.

link

 

 

Albumin and Cardiac Surgery Mortality

An observational study of on-pump cardiac surgery links the use of 5% Albumin to lower in-hospital mortality and lower 30 day readmission when Albumin + crystalloid was used compared to only crystalloid. Composite morbidity and acute kidney injury did not differ. Randomized studies would be needed to confirm these findings but Albumin seems to hold more promise than the now discredited colloids like hydroxyethyl starch.

link

 

Neuraxial Technique and Arthroplasty Outcome

A retrospective study on total hip and knee arthroplasty complications and correlation with neuraxial technique yields some interesting results. Whereas Combined Spinal Epidural (CSE) was the commonest technique, numerous post operative outcomes – cardiac, pulmonary, gastrointestinal, renal/genitourinary, and thromboembolic complications, and prolonged length of stay – were all lower in the Spinal Anesthesia group, suggesting an advantage for this technique. Pure epidural technique outcomes were no different from CSE.

link

 

Neuraxial Morphine / Diamorphine & Cesarean Respiratory Depression

A systematic review of the use of neuraxial Morphine and Diamorphine found that the highest and lowest prevalences of  clinically significant respiratory depression after Cesarean delivery with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62–8.77) and 1.08 per 10,000 (95% CI, 0.24–7.22), respectively. This study review is reassuring on the safety of neuraxial opioid analgesia at current practice doses (eg. 0.1 – 0.15mg spinal Morphine).

link

 

Opioid-Induced Adrenal Insufficiency

An important reminder of the endocrine effects of chronic opioid use, namely opioid induced adrenal insufficiency. Symptoms of adrenal insufficiency include fatigue, nausea, vomiting, weight loss, dizziness, and muscular aches, many of which overlap with or may compound symptoms related to chronic pain syndrome.  The etiology, diagnosis and management are discussed in this Mayo Clinic review. The possibility should be considered in all anesthesia and critically ill patients, and appropriate steroid supplementation instituted.

link