Outcomes

Propofol and Cancer Survival

Speculative and theoretical evidence has suggested Propofol anesthesia has less effect on immune function and cancer spread and this study finds remarkable evidence to support that Propofol based TIVA (total intravenous anesthesia) in colon cancer surgery is associated with better survival compared to Desflurane anesthesia, 33% vs 15%.

Several caveats include a retrospective study design, TNM staging, lack of blood use data and potential selection biases. Nonetheless this hypothesis needs more study and it is not unreasonable to use TIVA for cancer surgery taking this and other circumstantial evidence into account.

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Epinephrine for Out of Hospital Cardiac Arrest

Despite its central role in ACLS, the use of Epinephrine and outcome has been controversial. A major study finds “the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group”.

Postulated mechanisms include impairment of microvascular cerebral blood flow or possible reperfusion injury. So Epinephrine may improve survival but at a cost. The most important message to reiterate is how vital rapid CPR and defibrillation are.

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High Flow Nasal Oxygen & Length of Stay

The enthusiasm for high flow nasal oxygen continues unabated. This study was on high‐risk patients with pre‐existing lung disease (COPD, asthma, recent lower respiratory tract infection), heavy smokers or morbidly obese patients (body mass index (BMI) ≥ 35 kg.m−2), who were expected to stay longer in ICU and hospital due to increased respiratory complications after cardiac surgery.

When compared with standard oxygen therapy care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. The authors recommend routine use of high‐flow nasal oxygen after tracheal extubation in this cohort of patients and further testing of their hypothesis in large multi‐centre randomised trials.

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Cardiac Output Based Fluids for Kidney Transplant

A small study on fluids for deceased donor kidney transplantation compared esophageal Doppler based stroke volume optimization with conventional clinical practice. Complications and delayed graft failure were no different and the primary endpoint – amount of fluid given – did not significantly differ. Pending larger studies this does not support cardiac output based fluid administration during kidney transplantation.

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Albumin and Cardiac Surgery Mortality

An observational study of on-pump cardiac surgery links the use of 5% Albumin to lower in-hospital mortality and lower 30 day readmission when Albumin + crystalloid was used compared to only crystalloid. Composite morbidity and acute kidney injury did not differ. Randomized studies would be needed to confirm these findings but Albumin seems to hold more promise than the now discredited colloids like hydroxyethyl starch.

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Neuraxial Technique and Arthroplasty Outcome

A retrospective study on total hip and knee arthroplasty complications and correlation with neuraxial technique yields some interesting results. Whereas Combined Spinal Epidural (CSE) was the commonest technique, numerous post operative outcomes – cardiac, pulmonary, gastrointestinal, renal/genitourinary, and thromboembolic complications, and prolonged length of stay – were all lower in the Spinal Anesthesia group, suggesting an advantage for this technique. Pure epidural technique outcomes were no different from CSE.

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De-resuscitation of Fluid Overload and ICU Mortality

A retrospective cohort study on iatrogenic fluid overload in critically ill ventilated patients shows that a positive cumulative fluid balance on day three was associated with a higher mortality.  The largest contributions to fluid excess were maintenance and medication fluids rather than resuscitation fluids. Negative fluid balance achieved in the context of deresuscitative measures was associated with lower mortality.

This study supports recent trends in actively limiting maintenance and medication fluids along with deresuscitative measures such as diuretic usage and renal replacement therapy after the initial resuscitation  to achieve a negative fluid balance around  day three in the critically ill.

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Inferior Vena Cava Filters and Mortality

Inferior vena cava filters are widely employed for thromboembolism where contraindications to anticoagulation exist. This study has the limitations of being retrospective and observational and as such is hypothesis generating, but its conclusions are important and concerning in suggesting a higher 30 day mortality with use of caval filters in those with contraindications to anticoagulation.

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Cardiac Risk Prediction

A retrospective observational study compared well established cardiac risk prediction models: (i)the Revised Cardiac Risk Index, (ii)American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, and (iii)the Myocardial Infarction or Cardiac Arrest calculator.

While agreement was better between the latter two (ACS NSQIP and MICA), there was 30% discordance between assigning high or low risk compared to the RCRI.

The NSQIP certainly seems more modern and comprehensive than the RCRI but the divergence in risk assessment certainly needs to be borne in mind.

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Whole Blood Resuscitation

Increasing interest is being reported in returning to whole blood rather than component transfusion in trauma. Much of the earlier experience comes from military studies, many of which are subject to selection or survivial biases and retrospective in nature. The overall evidence and rationale, as well as risk, is summarized in this review, with the usual scenario being a combination of whole blood with combination products. Further study is required to define what place whole blood transfusion may have in resuscitation.

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