Chronic Pain Suicide Link

While this analysis is retrospective, it provides a concerning correlation between suicide and chronic pain, many dying from firearms or opioid overdose. Somewhere in the region of 10% had prior chronic pain. The study concludes: “Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety.”

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IV Anesthesia and Propofol History

The 2018 Lasker-DeBakey Clinical Medical Research Award has been awarded to John B. (Iain) Glen, a veterinarian, for the discovery and development of propofol, our go-to anesthetic induction agent. More unsavoury history recently related to its abuse in anesthesia residents (or in Michael Jackson’s death), as well as it’s appalling adoption for executions. A brief and fascinating history from JAMA

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Radiation Safety in Anesthesiology

Whereas most pediatric anesthesiologists had concerns about radiation safety, the findings in this study were quite concerning. “Dosimeters were rarely (13%) or never used (52%) and were mandated in only 28.5% of institutions. Virtually none of the respondents had ever taken a radiation safety course, received a personal radiation dose report, notification of their radiation exposure, or knew how many millirem/y was considered safe”.

It is reminiscent of non-scavenged ORs in the past where exposure to gases was common. The authors highlight the need for a safety culture in institutions and the need for more rigorous use of lead and thyroid shields, eye protection and dosimeter use.

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Sleep Apnea and Peri-operative Oitcomes

Obstructive Sleep Apnea is a red flag for surgery and anesthesia and ASA guidelines exist to identify and manage it peri-operatively, based on factors such as its severity, type/magnitude of surgery and need for postoperative opioids. The present study, although based on administrative data, is noteworthy as it involved a common ambulatory procedure, shoulder arthroscopy.

There was an increased risk of pulmonary complications, myocardial infarction, and an increased odds of requiring postoperative ventilation, hospital admission, and intensive care unit admission. These are significant for an ambulatory procedure and emphasize the need for caution in this population.

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Catheter-Over-Needle in Regional Anesthesia

A comparison was made between peripheral nerve blockade using catheter-through-needle and catheter-over-needle systems. There was no difference in analgesia or local anesthetic leakage, and the overall low rate of leakage was noteworthy. The catheter-over-needle system may have advantages in terms of speed of use and rate of inadvertent catheter dislodgement, but was associated with lower needle visibility on ultrasound.

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Intra-Operative Transfusion Guidelines

Electronic decision support tools as well as education may be necessary to encourage physicians to adopt best practices, as discussed in this article on “hemovigilance”. Newly qualified staff are more likely to adopt these practices as compared with attending physicians.

By and large the evidence is supportive of a restrictive blood transfusion policy with a Hemoglobin of 7g/dl as a target in hemodynamically stable patients. Some studies have led the AABB (formerly known as the American Association of Blood Banks) to use 8g/dl as a threshold in cardiac and orthopedic surgery as well as those with pre-existing cardiovascular disease.

The authors worryingly note: “One study found that 9.2% of intraoperative transfusions failed to meet a physiological indication (mean arterial pressure or heart rate) or a hemoglobin threshold <10 g/d”.

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Transversus Abdominis Plane Block in Children

“In children, quality of postoperative pain control provided by transversus abdominis plane (TAP) block using levobupivacaine 0.4 mg·kg−1 administered as either 0.2% or 0.4% did not differ and was associated with a very low risk of local anesthetic systemic toxicity”. The study involved inguinal day surgery and about 70% did not require any postoperative opioids. However the study only compared the two concentrations, there being no comparison with a control group not given the TAP block.

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Nicotine Replacement in Hospitalized Coronary Patients

Some concern exists as to the cardiac safety of using nicotine replacement patches in cardiac disease. The majority of studies indicate it safe to use in stable disease but this observational study is reassuring in finding: “Among smokers hospitalized for treatment of coronary heart disease, use of nicotine replacement therapy was not associated with any differences in short‐term outcomes”.

Outcomes included inpatient mortality, hospital length of stay, and one-month readmission.

These patients had a high degree of cardiac acuity but the authors caution that, due to the known cardiovascular effects of nicotine, randomized along with longer term studies are needed to confirm these reassuring findings in tackling smoking cessation at an early stage of hospitalization.

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Medical and health news weekly

Autism spectrum disorder is associated with depression in young adulthood  link

FDA investigating Juul and other e-cigarettes marketing to teenagers  link

Contaminated Valsartan with potential carcinogen NDMA investigation continues  link

SGLT2 inhibitors for diabetes may be rarely associated with necrotizing fasciitis of the perineum, Fournier’s gangrene  link

The FDA doesn’t seem to agree that coffee needs a cancer warning (as judged in California)  link

CDC issues comprehensive mild traumatic brain injury (‘concussion’)  guidelines in children  link

Probiotics labelled as useless by scientists  link

Whole grains reduce risk of type 2 diabetes  link

Milk increasing mucus/phlegm is an unscientific myth  link

 

Sugammadex Effectiveness in Elderly

Sugammadex was tested tested in elderly patients for reversing deep Rocuronium induced neuromuscular block. Increasingly seen as s faster and more complete agent compared to Neostigmine, this study found that low (as well as common clinical doses) were not as fast or effective in the elderly, and residual blockade and recurarization were more common. Renal function and obesity were risk factors also. The study highlights the need again for universal neuromuscular monitoring in all patients, even when Sugammadex is used.

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