Outcomes

ECMO for ARDS

A randomized study sought to answer the continuing debate over the utility of early extracorporeal membrane oxygenation for very severe ARDS.

“Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy“.

Bleeding and thrombocytopenia were higher in the ECMO group and ischemic stroke less.

There was a clear trend to better mortality but not clinically significant, and the trial was stopped early for futility. Experts question the statistical design and cutoff point for futility. There was also a sizeable crossover to rescue ECMO in the control conventional ventilation group. The debate is unlikely to end, and ECMO will probably remain in the armamentarium of severe ARDS treatment in expert centers as a viable choice.

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Extracorporeal Pediatric CPR

A small retrospective study of 56 Pediatric cardiac arrests (80% related to primary cardiac conditions), mean age 3.5 months (1-53).

Survival to hospital discharge was a very good c. 65%, best in younger age (3.5 months) and those with decreased extracorporeal CPR tones and those exposed to therapeutic hypothermia. Follow up showed a good quality of life and family functioning. Further studies are needed to establish whether the technique should be more widely available in Pediatric critical care.

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Anesthesia Neurotoxicity

The ongoing concern continues, albeit somewhat controversial, that general anesthesia may be neurotoxic. This observational study on over 60 year olds found elevated Neurofilament Light and Tau for 6 hours and remaining high at 48 hours after surgery. They are both markers of neuronal damage. Correlation with clinical outcome would require further studies but clearly the entire area of potential anesthesia neurotoxicity, particularly in the developing infant and toddler brain, as well as in the elderly, will remain an important sphere of research and concern.

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Oxygen and Wound Infection

A few studies suggested that using high oxygen  concentrations during and after surgery lowered surgical site infection rate. The World Health Organization has recommended FiO2 of 0.8 during and for many hours after surgery to help reduce wound infection. This is totally at odds with the increasing evidence of harm from hyperoxia and many anesthesiologists are reducing oxygen concentrations during surgery (apart from potential difficult airways). The WHO position seems simplistic and reductionist and a critique of their recommendation is found  here

 

Hydroxyethyl Starch Ban

Experts have vehemently argued over the European ban on HES, most agreeing on the evidence of increased renal failure and mortality. But a sizeable minority see it as unwarranted and draconian, such as this spirited critique of the flaws in the studies showing adverse outcomes. Note that one of the authors declares competing interest (Fresenius-Kabi makers of  Voluven HES)

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Restrictive Fluids in ERAS Harmful?

RELIEF Trial finds an increased risk of acute kidney injury in the most restrictive fluid protocols in abdominal surgery. They advocate “modestly liberal” fluid regimes. This is a surprise and counter to current regimes of Enhanced Recovery after Surgery (ERAS)

The issue is more nuanced depending on oral intake and how oliguria and hemodynamic perturbation is managed but the overall message seems to be that  ultra restrictive regimes need not necessarily dictate practice at the expense of the kidneys

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nejm editorial

 

Predicting Post Surgical Pain

An interesting blog on the need for better prediction tools to individualize surgery and anesthesia. Higher pre-surgical levels of pain catastrophizing and anxiety have been implicated in both acute and chronic post-surgical pain. PROMs (patient reported outcome measures) are increasingly used and need to incorporate these important emotional and psychological elements. Pinpointing them pre-operatively may lead to more focussed care.

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Acute Kidney Injury in ICU and Frailty

Both acute kidney injury in critical care and increased frailty in ICU survivors is frequent. This study shows a link between the occurrence of acute kidney injury and subsequent frailty:

Acute kidney injury in survivors of critical illness predicted worse frailty status 3 and 12 months postdischarge. These findings have important implications on clinical decision making among acute kidney injury survivors and underscore the need to understand the drivers of frailty to improve patient-centered outcomes”.

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