Early Neuromuscular Blockade in ARDS

The fashion that has returned for early neuromuscular block in ARDS was tested in this study.

“Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets”.


Neuraxial Anesthesia-Delivery time interval

Traditionally one of the more critically identified time frames after spinal anesthesia for Cesarean is the uterine incision to delivery time, and this is confirmed in this study.

After neuraxial anesthesia, uterine hypoperfusion from hypotension and maternal obesity may compromise the fetus. This study shows a direct correlation between increasing delay before delivery and decreasing umbilical artery pH.

“Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.”


Trans-Nasal Evaporative Intra-arrest Cooling

Much of the earlier enthusiasm for therapeutic hypothermia has been tempered with disappointing trial results. This study examined cooling of the brain initiated during cardiopulmonary resuscitation and its impact on survival with good neurologic outcome in patients with out-of-hospital cardiac arrest.

Trans-nasal evaporative intra-arrest cooling did not result in a statistically significant improvement in survival with good neurologic outcome.


Diaphragm and Pectoral Muscle Atrophy in ICU

Ultrasound was used to serially assess diaphragm and pectoral muscles in critical illness.

“Diaphragm and pectoral atrophy occurred in 48% and 29%, respectively, and was associated with septic shock (diaphragm) and steroid use (pectoral); atrophy of the two muscle types appears unrelated.”

The authors further note: “The diaphragm displayed clinically significant atrophy during the first 5 days of critical illness, especially in patients with septic shock, organ failure, or invasive mechanical ventilation. Given the small sample size, the study did not detect a link between atrophy of the diaphragm and clinical outcomes. Pectoral atrophy seemed confined to patients treated with steroids, and was associated with a poor outcome“.


Intraoperative Methadone

Methadone assisted treatment of substance use disorders is well known but its potential for perioperative analgesia is under appreciated.

This review (full text for ASA members or subscription) may be helpful to introduce it as a long lasting intravenous agent given at the beginning of surgery. Common doses are 0.1 – 0.3mg/kg or a single 20mg dose with 3 – 5mg in PACU q 20mins. Analgesia is generally quite prolonged for 24 hours or more, and most of the evidence provided here does not show a higher rate of respiratory depression.

Caution is advised in the elderly or morbidly obese or those with cardiovascular co-morbidities. Further studies are needed on its potential adverse effects on QT prolongation or serotonin syndrome, effects on chronic pain, use in ambulatory surgery and in enhanced recovery protocols.


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.”


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”.


Duration and Type of Surgical Prophylaxis and Adverse Events

While retrospective in nature, this study appears to confirm that antibiotic prophylaxis should not be unduly extended after surgery, as complications increase after 24 hours. Higher kidney injury rates occur with Vancomycin also.

Increasing duration of antimicrobial prophylaxis was associated with higher odds of acute kidney injury (AKI) and C difficile infection in a duration-dependent fashion; extended duration did not lead to additional surgical site infection (SSI) reduction. “These findings highlight the notion that every day matters and suggest that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI”.