Complications

Early Acute Kidney Injury and Outcome in Acute Respiratory Distress Syndrome

The authors carried out a secondary analysis of an observational study. Patients with severe respiratory failure were categorized based on worst serum creatinine or urine output.

Highlighting the significance of renal dysfunction, they concluded: The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.

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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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Metaraminol use during spinal anaesthesia for caesarean section

Phenylephrine has recently displaced Ephedrine as the pressor of choice for spinal induced hypotension during Cesarean Section. However an older agent makes a comeback in this study, although it has remained popular in some countries.

Conclusions:Metaraminol appears superior to ephedrine for the prevention of feto-maternal complications.

Metaraminol is associated with better umbilical arterial pH values than phenylephrine.

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Techniques and complications of awake fibre-optic intubation

A survey of Difficult Airway Society members sheds light on awake fibre optic intubation practices.

Most respondents (48%) had performed less than 5 within the last 2 years. Some (10%) had not performed any during this period.

Remifentanil was the most common sedative with local topicalisation and spray-as-you-go local anesthesia.

Complications did not differ between techniques, and included desaturation, multiple attempts or failed intubation.

The low numbers are a cause for concern in this still core technique and expert guidelines are awaited.

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Neuraxial labour analgesia reduces risk of maternal depression at 2 years after childbirth

This prospective study suggests another potential advantage to neuraxial analgesia for vaginal delivery.

It concluded: “For nulliparous women with single-term cephalic pregnancy planning for vaginal delivery, the use of neuraxial analgesia during labour was associated with a reduced risk of maternal depression at 2 years after childbirth.”

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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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Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics

Sometimes considered a nuisance, this study reminds us of the potential serious ramifications of accidental post-dural puncture headache (PDPH) during epidural placement in obstetrics.

The incidence of complications was not negligible in this retrospective review, including: composite of cerebral venous thrombosis and subdural hematoma, bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year post-delivery. 

Early recognition and management is therefore important.

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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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Peripheral Nerve Blocks for Ambulatory Shoulder Surgery

Nerve blocks are now almost universal during shoulder surgery for their superior analgesia. This study reviewed post-discharge outcomes.

A decrease in unplanned admissions was found. There was no improvement in other postoperative outcomes such as emergency department visits, readmissions, mortality, or practical costs.

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Cesarean Delivery and Neuraxial Opioids

This consensus statement from SOAP specifically addresses the use of neuraxial Morphine in Cesarean delivery and looks st dosing, safety and monitoring.

It clearly favours the use of neuraxial Morphine as part of a multimodal analgesia regime and how the benefits and risks may be addressed using appropriate monitoring.

It should be reviewed by all who provide Obstetric anesthesia.

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