Complications

Driving Pressure and Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome

Driving pressure is the difference between plateau pressure and positive end-expiratory pressure (PEEP), and is known to be associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). This has been demonstrated in controlled mechanical ventilation.

This study viewed it in the spontaneous ventilation/ weaning scenario. They established driving pressure and compliance could be reliably measured and an important finding that “Higher driving pressure measured during pressure support (assisted) ventilation significantly associates with increased intensive care unit mortality, whereas peak inspiratory pressure does not.”

Lower respiratory system compliance also significantly associates with increased intensive care unit mortality.

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Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty

This large national cohort “identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.”

Benzodiazepines and gabapentinoids were associated with higher odds of delirium, whereas lower risk of delirium was associated with neuraxial vs. general anesthesia, use of NSAIDs and COX2 Inhibitors, and high vs low opioid use specifically in the over 65 year olds.

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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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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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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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New Index for Preoperative Cardiovascular Evaluation

Another attempt to update or simplify prediction of cardiovascular morbidity and mortality in non-cardiac surgery.

Outcomes were: incidence of 30-day postoperative all-cause mortality, myocardial infarction (MI), or stroke.

This study identified six predictors of primary outcome: age ≥75 years, any history of heart disease, symptoms of angina or dyspnea with regular activities, hemoglobin <12 mg/dl, planned vascular surgery, and emergency surgery.

It is dubbed the Cardiovascular Risk Index (CVRI)

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In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis

This latest malpractice analysis still leaves concern for the outcomes in difficult tracheal intubation, showing outcomes still remain poor. Death is still a not uncommon occurrence.

The authors summarize: “Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.”

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