Complications

Proteinuria and Postoperative Kidney Injury

While proteinuria is well documented as a medical risk factor for morbidity, this retrospective review of pre-operative proteinuria in surgical patients finds: “Proteinuria was associated with postoperative acute kidney injury and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management”.

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Dural Sac Extent in Neonatal Caudal Block

An anatomic study in neonates sought to determine how close the dural sac was to the apex of the sacral hiatus, as this may lead to unintended spinal injection. Average distance in males was 10.9mm and 9.6mm in females; it increased with greater neonate length. Range was 4.9 -26.3mm.

“Anesthesiologists should be aware of the short distance between the sacral hiatus and the dural sac when performing caudal blocks, the shortest distance was 4.94 mm. Armed with this knowledge, caudal techniques should be modified to improve the safety and reduce the risk of complications, such as dural puncture.”

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Gastric Volume/Content in Elective Pediatric Surgery

This prospective cohort study aimed to identify “at risk” stomachs – with solid content or more than 1.25ml/kg in elective pediatric surgery. Median duration of fasting was 4 hours for liquids and >13 hours for solids. They found only 1% of elective children had potentially increased risk for pulmonary aspiration, but none had solid contents

While the overall findings are reassuring, they also draw attention to the often prolonged fasting times in pediatric surgery.

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Sleep Apnea and Peri-operative Oitcomes

Obstructive Sleep Apnea is a red flag for surgery and anesthesia and ASA guidelines exist to identify and manage it peri-operatively, based on factors such as its severity, type/magnitude of surgery and need for postoperative opioids. The present study, although based on administrative data, is noteworthy as it involved a common ambulatory procedure, shoulder arthroscopy.

There was an increased risk of pulmonary complications, myocardial infarction, and an increased odds of requiring postoperative ventilation, hospital admission, and intensive care unit admission. These are significant for an ambulatory procedure and emphasize the need for caution in this population.

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Nicotine Replacement in Hospitalized Coronary Patients

Some concern exists as to the cardiac safety of using nicotine replacement patches in cardiac disease. The majority of studies indicate it safe to use in stable disease but this observational study is reassuring in finding: “Among smokers hospitalized for treatment of coronary heart disease, use of nicotine replacement therapy was not associated with any differences in short‐term outcomes”.

Outcomes included inpatient mortality, hospital length of stay, and one-month readmission.

These patients had a high degree of cardiac acuity but the authors caution that, due to the known cardiovascular effects of nicotine, randomized along with longer term studies are needed to confirm these reassuring findings in tackling smoking cessation at an early stage of hospitalization.

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Sugammadex Effectiveness in Elderly

Sugammadex was tested tested in elderly patients for reversing deep Rocuronium induced neuromuscular block. Increasingly seen as s faster and more complete agent compared to Neostigmine, this study found that low (as well as common clinical doses) were not as fast or effective in the elderly, and residual blockade and recurarization were more common. Renal function and obesity were risk factors also. The study highlights the need again for universal neuromuscular monitoring in all patients, even when Sugammadex is used.

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Diclofenac cardiovascular risks

All NSAIDs have been linked to increased cardiac risks but this BMJ review singles next out Diclofenac (eg. Voltaren) as the worst agent. “The incidence rate ratio of major adverse cardiovascular events at 30 days among diclofenac initiators increased by 50% versus non-initiators, by 20% versus ibuprofen or paracetamol initiators, and by 30% versus naproxen initiator”.

Adverse events included atrial fibrillation or flutter, ischaemic stroke, heart failure, myocardial infarction, and cardiac death; both sexes of all ages; and even at low doses of diclofenac.

Risk of upper gastrointestinal bleeding at 30 days with diclofenac was similar to that of naproxen, but much higher than for no NSAID initiation, paracetamol, and ibuprofen.

Encountering such patients in the pre-admission setting is an opportunity for counselling and risk mitigation.

Adverse side effects of dexamethasone in surgical patients

A single dose of Dexamethasone is widely used in anesthesia as an anti-emetic. This Cochrane review sought to assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients.

They found a single dose of Dexamethasone did not increase infection within 30 days. The data was inconclusive on wound healing, and there was some increase in blood sugar. They caution on extrapolating such data where infection and wound healing may be more likely, such as diabetes or immunodeficiency. Also the surgeries were very heterogeneous, including cardiac, abdominal, neurosurgery, orthopedic etc. and no differentiation is mentioned between elective and emergency surgery. Further studies are awaited.

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Lidocaine for Anesthesia-Related Cough

While Lidocaine has been demoted in ACLS and cardiology, it has enjoyed a renaissance in Anesthesia and Pain Medicine. Intravenous bolus and infusion are being used in opioid-sparing anesthesia and to speed recovery of bowel function and provide analgesia ( link ).

This meta-analysis and review may provide another rationale for its use in anesthesia. Some caution is in order especially for those at risk of cardiac or systemic toxicity, as reports of adverse effects are sparse. It is important to co-ordinate with the surgeon to guard against concurrent local anesthesia infiltration or epidural/nerve blocks that could risk such toxicity.

‘The conclusion: Within a range of 0.5–2 mg·kg−1, intravenous lidocaine dose-dependently prevents intubation-, extubation-, and opioid-induced cough in adults and children with NNTs ranging from 8 to 3. The risk of harm in high-risk patients remains unknown.

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