Diaphragm and Pectoral Muscle Atrophy in ICU

Ultrasound was used to serially assess diaphragm and pectoral muscles in critical illness.

“Diaphragm and pectoral atrophy occurred in 48% and 29%, respectively, and was associated with septic shock (diaphragm) and steroid use (pectoral); atrophy of the two muscle types appears unrelated.”

The authors further note: “The diaphragm displayed clinically significant atrophy during the first 5 days of critical illness, especially in patients with septic shock, organ failure, or invasive mechanical ventilation. Given the small sample size, the study did not detect a link between atrophy of the diaphragm and clinical outcomes. Pectoral atrophy seemed confined to patients treated with steroids, and was associated with a poor outcome“.


Intraoperative Methadone

Methadone assisted treatment of substance use disorders is well known but its potential for perioperative analgesia is under appreciated.

This review (full text for ASA members or subscription) may be helpful to introduce it as a long lasting intravenous agent given at the beginning of surgery. Common doses are 0.1 – 0.3mg/kg or a single 20mg dose with 3 – 5mg in PACU q 20mins. Analgesia is generally quite prolonged for 24 hours or more, and most of the evidence provided here does not show a higher rate of respiratory depression.

Caution is advised in the elderly or morbidly obese or those with cardiovascular co-morbidities. Further studies are needed on its potential adverse effects on QT prolongation or serotonin syndrome, effects on chronic pain, use in ambulatory surgery and in enhanced recovery protocols.


Off or On Pump CABG

Much hope for improvement in outcomes and cognitive impairment was held out for off pump CABG. This study shows no difference.

“The present study’s data did not show differences in key long-term outcomes between patients who underwent revascularization with or without cardiopulmonary bypass, supporting the idea that both methods achieve similar late results regarding overall survival, need for reintervention, and postoperative myocardial infarction.”


Dexamethasone IV and Spinal Anesthesia

A systematic literature search followed by conventional meta‐analysis examined the effects of intravenous Dexamethasone during Spinal Anesthesia.

While its effects on nausea and vomiting are well known, this study found a high level of evidence that intravenous dexamethasone improves postoperative analgesia after spinal anaesthesia.

Dexamethasone use was associated with a significant reduction in 24‐h morphine consumption and times to first analgesia request was prolonged by 86 mins.


Monitored anaesthesia care for gastrointestinal endoscopy in children

An observational study to identify the prevalence and predictors of adverse events during sedation for paediatric endoscopy. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively.

12 independent predictors: age, children’s size for example underweight/overweight, morbid obesity, presence of respiratory comorbidities, recent respiratory infection, neurological comorbidities, upper gastrointestinal endoscopy, propofol co-administration with ketamine or after sevoflurane induction, and propofol induction dose.

Posthoc secondary analyses revealed a significantly higher risk of adverse events and also significantly more respiratory comorbidities and respiratory infections in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed.

Adverse events were rare but predictable and pediatric endoscopy is safe in experienced hands.


Phenylephrine vs. Norepinephrine in Cesarean

A growing interest in the use of small bolus Norepinephrine (Noradrenaline) for Cesarean hypotension is based on its presumed lesser tendency to cause bradycardia compared to Phenylephrine.

This small study compared the effects of 100 μg phenylephrine and 5 μg norepinephrine and found no difference in maternal bradycardia. The number of boluses needed was higher in the Phenylephrine group.

“However, in view of the lower umbilical artery pH when using noradrenaline, further research is warranted to study its placental transfer and fetal metabolic effects”.

Surgeon Special Interest and Mortality

Another set of data analysis from NELA correlated surgeon special interest in either colorectal or upper gastrointestinal surgery with outcome.

“Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 day”.

The authors note the implications for emergency service configuration, training and workforce provision, “and should stimulate discussion among all stakeholders”.


Medical & Health News Weekly

New type of dementia identified link

An association between poor sense of smell and an increased risk of death link

Ebola outbreak in Congo continues amid suspicion and attacks on health care workers link

FDA warning on sleepwalking and other dangerous behaviours with common prescription sleep medications link

Canadian cigarettes to have plain packaging link

Cialis for heart failure? Unsurprising, as that’s what they were initially developed for link

Vampire facials are not based on any credible evidence; now unsafe spa practice linked to HIV link

Cruise ship quarantined for reported disease once thought to be near extinct. And measles rolls on as quackery triumphs science link

If you could stop eating your placenta, that’d be great; no benefits and risks exist, including products such as pills link

Paravertebral Block

Many situations where epidurals were previously employed now use techniques such as paravertebral block.

This free full text review provides an excellent brief survey of the anatomy, and both older landmark-based and current ultrasound-guided techniques, uses in thoracic/abdominal/breast surgeries, and complications.

Also discussed are the so-called “paravertebral by proxy” blocks that indirectly spread there – erector spinae, midpoint transverse process, retro-laminar, and intercostal paraspinal blocks. These may become preferred approaches in less specialized hands where injury to pleura is likely to be less.