Perioperative Methadone for Analgesia

While Methadone is well known for its role in medication assisted treatment for substance use disorders, its long duration of analgesia has perhaps been under-appreciated for surgical analgesia. In addition to its opioid action it has anti-hyperalgesic and anti-allodynic properties through NMDA antagonism, and Serotonin-Norepinephrine re-uptake inhibition. Doses generally given are 20mg or 0.2mg/kg. Studies indicate 24 hours or more analgesia with reduced need for supplemental analgesia.

Studies are ongoing as to its safety in different at-risk populations, e.g. coexisting medications, older, frail, cardiorespiratory disease, OSA, but this APSF article provides a great primer on Methadone in the perioperative period.

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WHO Surgical Safety Checklist In Emergency Laparotomy

A global cohort study explored the use and impact of the WHO Surgical Safety Checklist in emergency laparotomy. Once again, the findings were striking in that checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐Human Development Index (HDI) countries was half that in high‐HDI countries.

The authors importantly note that the association with lower mortality “is likely to reflect broader health system differences that prioritize safe and effective surgical care, yet the checklist plays an important part”. It focuses a team on better communication, collaboration, empowerment and behavioural changes.

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Multimodal Prehabilitation

There is growing evidence for the use of prehabilitation before major surgery to maximize patients’ nutrition, physical condition and cardiovascular fitness, respiratory status and psychological well-being. This is particularly important in cancer surgery. Patients commonly report reduced functional capacity, pain, fatigue, reduced sleep and appetite long after discharge.

There is a window, albeit narrow, before surgery to implement the supervised exercise and nutritional optimization discussed in this article in Anaesthesia, especially in at risk patients – frail, elderly or cancer patients. Concurrently, optimization of respiratory function, anemia correction, smoking cessation, diabetes and cardiac status should occur.

The logistics and economic ramifications will clearly need to be addressed.

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Shared Decision-Making in Perioperative Medicine

Anaesthesia brings another review of the process of shared decision-making that has come to the fore with new patient expectations, healthcare structures and law.

The emphasis is not merely on “informed consent”, but using decision aids to fully explore management options in light of the patient’s preferences and values. The article explores the issue that neither bombarding the patient with details nor cursorily “consenting” the patient are adequate.

The obstacles are discussed, with the often brief encounter with Anesthesia, as well as how it may be implemented in advance of surgery or in the Pre-Admission scenario. It is an interactive dialogue that goes beyond information provision.

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High Volume Fluid and Pediatric Colectomy Outcome

Restrictive fluid administration has become the standard of care in major abdominal surgery in adults as part of ERAS (enhanced recovery); the RELIEF trial sounded the only caution in terms of renal risk ( link ).

This pediatric paper extends the doctrine in that high volume fluids were associated with increased length of stay, longer time to first meal, and longer need for supplemental oxygen.

The conclusion is that high volume fluid administration during colectomy for pediatric patients is associated with worsened postoperative outcomes suggestive of impaired recovery.

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Intranasal Ketamine for Extremity Injuries in Children

A small non-inferiority study on children aged 8- 17 with extremity injuries (mostly fractures) compared intranasal Ketamine 1.5 mg/kg with Fentanyl 2 mcg/kg.

Ketamine produced effective analgesia that was non-inferior to Fentanyl, but did have more what are characterized as minor side effects, eg. dizziness or somnolence; these were short-lived. No serious adverse events, such as respiratory or hemodynamic, occurred.

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Diabetic Gastric Residual Volume

A study of 50 patients using both gastric ultrasound and nasogastric aspiration compared patients with diabetes for more than 6 years with healthy controls, after undergoing anesthesia for elective surgery. Patients with long standing diabetes showed higher residual gastric volume compared to healthy controls after fasting 8 hours for elective surgery, confirming most anesthesiologists’ beliefs. This may alter the NPO approaches to such patients as well as the anesthetic technique, although whether these findings affect complication rates or outcome is not addressed.

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80% Oxygen during Surgery?

High FiO2 is recommended by the WHO to reduce surgical infections. Concern exists however re the growing evidence of the potential harms and adverse or worse outcomes from too much oxygen in many settings like MI, stroke, lung injury, brain injury and ACLS leading to important recommendations to limit oxygen based on adequate SpO2 values. ( blog link ) This current paper fails to find harm from high FiO2 in terms of atelectasis, cardiovascular events, ICU admission or death.

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Numerous critiques of the WHO recommendation exist eg.

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Pre‐operative respiratory optimization

An expert review of respiratory optimization from Anaesthesia.

It discusses the evidence for approaching conditions such as COPD, Asthma, Obstructive Sleep Apnea and Smoking. A review of the evidence is provided on smoking cessation, exercise testing, exercise training, respiratory muscle training, and how they may impact improved respiratory outcomes post-operatively.

Acute respiratory infections, low Oxygen Saturation or uncontrolled symptoms or signs may be the most clear cut reasons for delaying elective surgery.

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Medical and Health News Weekly

Ebola virus still not controlled in DRC link

Mediterranean diet is the best one! link

Genetic basis why males with glioblastoma fare worse link

Experts again warn of cannabis induced psychosis link

Doctors write social prescriptions for loneliness, depression and anxiety link

Brain dead woman that spurs legal battle to keep on life support dies link

“Southern Diet” is a big reason for the racial gap in hypertension link

AMA warns of direct-to-consumer genetic and other tests – false negatives and positives, non-evidence based and non-guideline based link

Systematic review finds no strong evidence that non-sugar sweeteners have any health outcome benefits link

Fentanyl test strips to ensure your cocaine and heroin are uncontaminated – controversial link