Reducing pain in infants, children, and adolescents

This Cochrane Special Collection highlights the evidence for reducing both chronic and acute pain in infants, children, and adolescents.

Some areas are still devoid of good evidence, but this review includes links to a large number of topics. Chronic pain topics include the use of antidepressants, anti-epileptics, NSAIDS, acetaminophen, and opioids in non-cancer pain. A list of reviews of different opioids for cancer pain is included. Various opioids as well as psychological interventions are surveyed in acute pain management.

The list is comprehensive and full text is available at:

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Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock

Numerous studies have advocated combinations of Thiamine, Vitamin C and Steroids in septic shock in adults, but randomized studies have yet to convince majority opinion on outcome improvement.

This Pediatric study used Thiamine and reported improvements in Lactate clearance, but again this is a surrogate outcome measure and does not demonstrate mortality improvement, nor does it prove causation. So it re-emphasizes the need for further randomized controlled studies.

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Vitamin C, Steroids and Thiamine for Sepsis

One might be forgiven for assuming that this is a “revolutionary” and “astounding” treatment for sepsis – the cocktail of steroids, high dose vitamin C and Thiamine propounded almost by a single person, Dr. Paul Marik, based on tiny observational personal studies.

This is an important commentary on the state of wild claims not supported by a single randomized trial in Sepsis.

It is dubbed “science by press release” in this JAMA article. While everyone hopes for a new effective treatment for Sepsis, hype ahead of the evidence is not the way of science.

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Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block

Hemi-diaphragmatic paralysis from Phrenic Nerve Block is a frequent accompaniment to Interscalene Brachial Plexus Block that may be detrimental to those with compromised respiratory function.

This randomized trial compared the more selective targeting of the nerves using the more novel Superior Trunk Block employing ultrasound.

Conclusions: “Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.”

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New Index for Preoperative Cardiovascular Evaluation

Another attempt to update or simplify prediction of cardiovascular morbidity and mortality in non-cardiac surgery.

Outcomes were: incidence of 30-day postoperative all-cause mortality, myocardial infarction (MI), or stroke.

This study identified six predictors of primary outcome: age ≥75 years, any history of heart disease, symptoms of angina or dyspnea with regular activities, hemoglobin <12 mg/dl, planned vascular surgery, and emergency surgery.

It is dubbed the Cardiovascular Risk Index (CVRI)

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In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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Suicide in Anesthesiologists

Light is shed upon this once taboo subject in this Association of Anaesthetists survey. The entire spectrum of stress, depression, burnout, sleep deprivation, etc. is now a pressing issue in healthcare professionals. Anesthesiologists have ready access to potent medications, posing addiction risks as well as intentional or accidental fatal overdose.

This survey looked at experiences of colleague suicide as well as the support schemes in place, and awareness of same.

Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads. Deficiencies were noted in the support available and in the way the deaths were handled.

The authors summarize their paper: “emphasizes the need for continued work in promoting discussion, awareness and support of mental health issues, including work‐related stress and alcohol/drug misuse, throughout healthcare systems and anaesthetic departments. We hope that the Association of Anaesthetists guidance, currently in preparation, will provide a useful resource for individuals and departments in this area.”

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Unprofessional Behavior by Surgeons and Surgical Complications

Unprofessional or what is known as disruptive behaviour has been shown to be rife in hospitals. This retrospective study tested the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications.

The conclusion: “Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. ”

The authors point out that “optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.”

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Blood Purification and Mortality in Sepsis and Septic Shock

A systemic review and meta-analysis of a variety of modalities such as hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique were compared to conventional therapy in adult patients with sepsis and septic shock.

“Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock.”

Clearly the evidence for these “blood purification” strategies will require further randomized higher quality trials before they can be routinely recommended.

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis

This latest malpractice analysis still leaves concern for the outcomes in difficult tracheal intubation, showing outcomes still remain poor. Death is still a not uncommon occurrence.

The authors summarize: “Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.”

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