Sugammadex in the Elderly

A study using low dose Sugammadex (0.4mg/kg) showed that recovery of train-of-four ratios was slower and recurarization was more common in the elderly after Rocuronium neuromuscular blockade. Renal dysfunction and obesity imposed a higher risk; even 4mg/kg may not suffice in some. The bottom line in all elderly patients is that neuromuscular monitoring is just as imperative with Sugammadex as other agents in ensuring adequate reversal.

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Propofol vs. Inhalational Anesthesia

A systematic review and meta-analysis finds that Propofol anesthesia provides better patient satisfaction, pain scores and an especially better nausea and vomiting outcome as compared with inhalational anesthesia, with a marginal increase in time for respiratory recovery and extubation.

While some recent studies have yielded opposing results on the effect of total intravenous anesthesia on cancer recurrence and mortality, there seems ample reason to choose Propofol based anesthesia. Further prospective validating studies are suggested.

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Weekly Medical & Health News

FDA approves Dsuvia (sublingual Sufentanil, or Dzuveo), new opioid formulation widely criticized by experts  link

The American Academy of Pediatrics recommends against spanking, yelling or shaming which is associated with negative behavioral, cognitive, psychosocial, and emotional outcomes for children link

Still too many tonsillectomies in UK. link

Short interpregnancy intervals appear to be associated with increased risks for adverse pregnancy outcomes  link

Dietary salt restriction for heart failure is very poorly supported by evidence  link

Young adults (under 40 years) with hypertension may be at increased risk of cardiovascular disease, even stage 1 hypertension (systolic blood pressure, 130-139 mm Hg or diastolic blood pressure, 80-89 mm Hg)   link

The NRA takes aim at doctors who counsel patients on gun safety and its perception as a public health crisis  link

 

Physician Burnout

We are in the midst of an epidemic of physician fatigue, burnout, depression and suicide, concepts previously unspoken and felt to be signs of weakness in the ‘resilient ‘ physician.

A meta-analysis of 47 studies encompassing over 42,000 physicians found that burnout is associated with 2-fold increased odds for unsafe care, unprofessional behaviors, and low patient satisfaction. Depersonalization was in particular linked, and the findings were stronger in early career physicians.

The authors recommend that organizations invest in efforts to improve physician wellness, particularly for early-career physicians.

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Suicide

Professor Steve Robson is President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and is a member of the Australian Medical Association Federal Council.

This frank article recollects a more troubled time in his life. At the end, scroll to comment number 30 to complete the scenario. Stress, fatigue, burnout, depression and suicide are now at crisis levels and a Canadian Medical Association survey ( link )reported a startling 8% rate of physician suicidal ideation in the previous 12 months (15% in residents).

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National Emergency Laparotomy Audit (NELA)

The National Emergency Laparotomy Audit (NELA)  2016-2017 is released and provides information on how performance in England and Wales matches benchmarks, and how institutions can compare their performance.

Overall, compared with 2013:

  • hospital stays are about 15 days (4 days less)
  • 30 day mortality 9.5% (down from 11.8%)
  • 87% received a pre-operative CT Scan (up from 80%)
  • One year mortality was 77%, and three year mortality 66%
  • 75% of patients now receive an assessment of risk (up from 71% last year, and 56% in Year 1).

More negative findings were:

  • 76% of patients with sepsis did not receive antibiotics in the one-hour time frame.
  • 77% did not receive geriatric consult even though half were over 70 years old
  • 27% of patients needing the most urgent surgery did not get to the Operating Room in the recommended timeframes
  • Only 66% of consultant anesthesiologists and surgeons (attending physicians) were present in the OR after hours, and 90% during daytime.

NELA Recommendations include:

1. improving outcomes and reducing complications
2. ensuring all patients receive an assessment of their risk of death
3. delivering care within agreed timeframes for all patients
4. enabling consultant input in the perioperative period for all high risk patients
5. effective multidisciplinary working
6. supporting quality improvement.

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Energy-Dense vs. Routine Enteral Nutrition in ICU

Critically ill patients often receive less than recommended amounts of nutritional support and this study compared energy-dense (1.5 kcal per milliliter) with routine (1.0 kcal per milliliter) enteral nutrition at a dose of 1 ml per kilogram of ideal body weight per hour, commencing at or within 12 hours of the initiation of nutrition support and continuing for up to 28 days while the patient was in the ICU. The primary outcome was all-cause mortality within 90 days.

No advantage was found with the energy-dense formulation in these patients on mechanical ventilation, the rate of 90 day survival being no different. Neither was there any difference in infective events or need for organ support.

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Acute Pain in Buprenorphine-Maintained Patients

Buprenorphine is increasingly encountered as a maintenance agent in substance use disorders rather than Methadone. Analgesia in such patients is challenging due to the complex partial agonist and antagonist properties of this agent.  Strategies include continuing buprenorphine for minor surgeries – often dividing the daily dose, or stopping it before surgery and using other opioids for analgesia in major surgery.

This study found that in those maintained on 12-16mg daily with last dose c. 17 hours ago,  up to 32mg of either IV Hydromorphine or Buprenorphine was effective. “However, the use of hydromorphone for analgesia in buprenorphine-maintained individuals confers greater abuse liability and side effects than does supplemental intravenous buprenorphine”. Analgesia requirement, side effects, drug interactions and factors like whether Buprenorphine is stopped or continued must all be taken into account.

Acupuncture for Post-Operative Nausea and Vomiting

Acupuncture has long been used for nausea and vomiting in different scenarios using the P6 point on the anterior forearm above the wrist. Studies have always been lower quality, with study blinding issues and  sham acupuncture being potentially effective also. A Cochrane review nonetheless concluded it to be comparable  to anti-emetics ( link ).

This latest study finds a significant reduction in nausea (more than vomiting) in the recovery period even when added to anti-emetics. The study was in children 3-9 years of age undergoing adenotonsillectomy. All patients received Ondansetron and Dexamethasone. There was no difference after 24 hours.

P6 acupuncture appears a simple measure without significant side-effects to consider for post-operative nausea and vomiting prevention.

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Anesthesia, Surgery and Child Development

The huge area of research into the potential neurotoxicity of anesthetics in Pediatric Anesthesia has yielded reassuring results on the whole but some suggestions that multiple or prolonged anesthesias may be harmful in terms of learning and behavioural issues.

This sibling-controlled cohort study used the Early Development Instrument (EDI) and population-based health and demographic administrative databases to try to account for the many confounding variables in child development, e.g. genetic, perinatal, familial, environmental, social, educational.

The authors found “no differences in the adjusted odds of early developmental vulnerability or performance in any major developmental domain between biological siblings after exposure to surgical procedures that require general anesthesia”. They suggest anesthesia is a marker of vulnerability and does not reflect a causative pathway for adverse child development.

As an observational study, it is not the final word, but its findings are somewhat reassuring. Further study is still important in terms of types and duration of anesthesia not defined here. The advice for now remains the same that needed surgery should not be delayed based on current evidence in Pediatric Anesthesia.

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