Pharmacology

Gabapentinoids and Adverse Postoperative Respiratory Outcomes

This study examined the association between gabapentinoids on the day of surgery and adverse postoperative outcomes in patients undergoing colorectal surgery in the United States.

Their use was associated with only a slightly lower opioid use on the day of surgery but a higher odds of non-invasive ventilation and naloxone use after surgery.

It highlights the fact that before blindly implementing enhanced recovery protocols, a firm evidence base should be established, as opioid-phobia may paradoxically result in unintended adverse events.

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Sugammadex and Postoperative Myasthenic Crisis

This was a database study with its inherent limitations but looked at adults with Myasthenia Gravis undergoing thymectomy and postoperative outcomes, specifically examining the use of Sugammadex.

They found that sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs and length of stay, but no differences in the secondary outcome of postoperative pneumonia.

They advocate the routine use of Sugammadex in such patients.

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Postoperative Sore Throat

This so-called minor complication after general anesthesia was subject to review in this editorial accompanying a study. It has been described in 20-40% of patients.

Risk factors include female, younger age, a history of smoking or lung disease, longer duration of anesthesia, postoperative nausea, natural teeth (vs dentures), blood visible on the endotracheal tube at extubation, intubation techniques and larger diameter tracheal tubes.

Deserving more attention due to its discomfort even though short lived (< 48hours), remedies to reduce its incidence include intravenous dexamethasone, topical benzydamine, topical corticosteroids, lidocaine (either intra-cuff or intravenously administered), ketamine, with even the choice of volatile anesthetic playing a role (desflurane is associated with a higher incidence of POST than sevoflurane).

The editorial references a systematic review and meta-analysis in topical Magnesium. Both dose (100–500 mg, 20 mg·kg−1, or not stated at all) and delivery (gargle, lozenge, or nebulization) of topical magnesium were highly variable. While effective, it needs to be compared to other management strategies.

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Prolonged Perioperative Use of Pregabalin and Ketamine & Chronic Pain

This was a randomized study in cardiac surgery. Patients were randomly assigned to receive either usual care, pregabalin (150 mg preoperatively and twice daily for 14 postoperative days) alone, or pregabalin in combination with a 48-h postoperative infusion of intravenous ketamine at 0.1 mg · kg−1 · h−1.

Conclusions: Preoperative administration of 150 mg of pregabalin and postoperative continuation twice daily for 14 days significantly lowered the prevalence of persistent pain after cardiac surgery.

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Patient Outcomes & Pharmacist Participation in Multidisciplinary Critical Care Teams

This systematic review and meta-analysis studied the effect of pharmacist involvement in critical care.

The results encourage multidisciplinary care beyond medical teams alone:

“Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.”

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Early Sedation with Dexmedetomidine in Critically Ill Patients

Dexmedetomidine has become an agent touted to reduce delirium, sedate without respiratory depression and improve analgesia in both OR and ICU settings.

This study examined its use as a sole early sedation agent in critically ill patients. Results were not overly impressive.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and and required supplemental sedatives to achieve the prescribed level of sedation. More adverse events were reported in the dexmedetomidine group”

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SGLT Inhibitors and Diabetic Ketoacidosis

The popularity of SGLT Inhibitors has increased with purported cardiovascular and renal benefits. Issues have arisen however and this consensus addresses the reported cases of normoglycemic diabetic ketoacidosis.

Pertinent to perioperative care, “SGLT inhibitors should be withheld or discontinued prior to any medical procedure (ideally for 3 days), particularly if the patient will be reducing food intake or will not be allowed to eat or drink for some time before and after the procedure.”

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Tramadol and Persistent Opioid Use

Faced with the opioid epidemic, many have turned to postoperative use of Tramadol in the belief it has less misuse potential.

This observational study finds however that: “People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids”.

They advocate reclassifying Tramadol and urge caution in its prescription.

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Intraoperative Seizures During Elective Craniotomy

This retrospective study found that the incidence of intraoperative seizures during elective craniotomy with evoked potential monitoring is low. 

The overall incidence of intraoperative seizures was 2.3%. Independent risk factors for intraoperative seizures were seizure history, diagnosis of intracranial tumor, and temporal craniotomy. 

Intraoperative prophylactic anticonvulsant use was protective.

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