Complications

SGLT Inhibitors and Diabetic Ketoacidosis

The popularity of SGLT Inhibitors has increased with purported cardiovascular and renal benefits. Issues have arisen however and this consensus addresses the reported cases of normoglycemic diabetic ketoacidosis.

Pertinent to perioperative care, “SGLT inhibitors should be withheld or discontinued prior to any medical procedure (ideally for 3 days), particularly if the patient will be reducing food intake or will not be allowed to eat or drink for some time before and after the procedure.”

Full text link

Tramadol and Persistent Opioid Use

Faced with the opioid epidemic, many have turned to postoperative use of Tramadol in the belief it has less misuse potential.

This observational study finds however that: “People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids”.

They advocate reclassifying Tramadol and urge caution in its prescription.

link

Intraoperative Seizures During Elective Craniotomy

This retrospective study found that the incidence of intraoperative seizures during elective craniotomy with evoked potential monitoring is low. 

The overall incidence of intraoperative seizures was 2.3%. Independent risk factors for intraoperative seizures were seizure history, diagnosis of intracranial tumor, and temporal craniotomy. 

Intraoperative prophylactic anticonvulsant use was protective.

link

Post Dural Puncture Headache Treatment

A new guideline from the Obstetric Anaesthetists Association underlines how little evidence is really available to guide management of post dural puncture headache. Epidural Blood Patch remains the best treatment but in general is more effective after 48 hours. Some relief occurs in up to 80%, and complete resolution of pain in about a third. It may need repeating. 20mL blood is suggested or less if back pain develops.

There is insufficient evidence on a whole host of suggested treatments – steroids, gabapentinoids, ACTH, caffeine, triptans, theophylline, neostigmine and atropine, acupuncture, various nerve blocks, and epidural crystalloid.

link

Propofol and Food Allergies

There is some disquiet about using Propofol in those with allergies. This was a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia.

In 9 out of 10 meeting allergic reaction criteria, valid non‐allergic explanations for the clinical symptoms were found.

The authors conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

link


Off or On Pump CABG

Much hope for improvement in outcomes and cognitive impairment was held out for off pump CABG. This study shows no difference.

“The present study’s data did not show differences in key long-term outcomes between patients who underwent revascularization with or without cardiopulmonary bypass, supporting the idea that both methods achieve similar late results regarding overall survival, need for reintervention, and postoperative myocardial infarction.”

link

Monitored anaesthesia care for gastrointestinal endoscopy in children

An observational study to identify the prevalence and predictors of adverse events during sedation for paediatric endoscopy. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively.

12 independent predictors: age, children’s size for example underweight/overweight, morbid obesity, presence of respiratory comorbidities, recent respiratory infection, neurological comorbidities, upper gastrointestinal endoscopy, propofol co-administration with ketamine or after sevoflurane induction, and propofol induction dose.

Posthoc secondary analyses revealed a significantly higher risk of adverse events and also significantly more respiratory comorbidities and respiratory infections in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed.

Adverse events were rare but predictable and pediatric endoscopy is safe in experienced hands.

link

Surgeon Special Interest and Mortality

Another set of data analysis from NELA correlated surgeon special interest in either colorectal or upper gastrointestinal surgery with outcome.

“Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 day”.

The authors note the implications for emergency service configuration, training and workforce provision, “and should stimulate discussion among all stakeholders”.

link