Neuraxial Technique and Arthroplasty Outcome

A retrospective study on total hip and knee arthroplasty complications and correlation with neuraxial technique yields some interesting results. Whereas Combined Spinal Epidural (CSE) was the commonest technique, numerous post operative outcomes – cardiac, pulmonary, gastrointestinal, renal/genitourinary, and thromboembolic complications, and prolonged length of stay – were all lower in the Spinal Anesthesia group, suggesting an advantage for this technique. Pure epidural technique outcomes were no different from CSE.

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De-resuscitation of Fluid Overload and ICU Mortality

A retrospective cohort study on iatrogenic fluid overload in critically ill ventilated patients shows that a positive cumulative fluid balance on day three was associated with a higher mortality.  The largest contributions to fluid excess were maintenance and medication fluids rather than resuscitation fluids. Negative fluid balance achieved in the context of deresuscitative measures was associated with lower mortality.

This study supports recent trends in actively limiting maintenance and medication fluids along with deresuscitative measures such as diuretic usage and renal replacement therapy after the initial resuscitation  to achieve a negative fluid balance around  day three in the critically ill.

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Neuraxial Morphine / Diamorphine & Cesarean Respiratory Depression

A systematic review of the use of neuraxial Morphine and Diamorphine found that the highest and lowest prevalences of  clinically significant respiratory depression after Cesarean delivery with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62–8.77) and 1.08 per 10,000 (95% CI, 0.24–7.22), respectively. This study review is reassuring on the safety of neuraxial opioid analgesia at current practice doses (eg. 0.1 – 0.15mg spinal Morphine).

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Inferior Vena Cava Filters and Mortality

Inferior vena cava filters are widely employed for thromboembolism where contraindications to anticoagulation exist. This study has the limitations of being retrospective and observational and as such is hypothesis generating, but its conclusions are important and concerning in suggesting a higher 30 day mortality with use of caval filters in those with contraindications to anticoagulation.

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Medical News Weekly

LABAs do not confer extra risk in asthma – as long as they are combined with inhaled steroids  link

Patients prefer formal attire with white coat for primary care and hospital doctors – but scrubs for surgeons and ER docs (go figure!)   link

The use of surgical mesh for stress urinary incontinence is to be suspended immediately in the UK.  link

Multivitamins don’t improve cardiovascular outcomes. Use the money for healthy food!  link

Fluoroquinolones to carry warning re hypoglycemia and mental/cognitive effects  link

Possible increase in thromboembolism and stroke in transgender (trans feminine) people given estrogens link

Vaping nicotine products may not help smokers quit, despite their promotion as such  link

The USPSTF finds insufficient evidence to assess the balance of benefits and harms of adding the ABI, hsCRP level, or CAC score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events  link

To survive an in-hospital cardiac arrest, it helps to be white!  link

NSAIDS and anticoagulants concomitantly increase bleeding and stroke risks  Link

CDC warns of increasing deaths from Fentanyl and its analogs like Carfentanil whose potency may necessitate multiple doses of Naloxone  link

Low dose aspirin <100mg ineffective if over 70kg  link

Several Valsartan containing meds are recalled due to contamination  link

 

Opioid-Induced Adrenal Insufficiency

An important reminder of the endocrine effects of chronic opioid use, namely opioid induced adrenal insufficiency. Symptoms of adrenal insufficiency include fatigue, nausea, vomiting, weight loss, dizziness, and muscular aches, many of which overlap with or may compound symptoms related to chronic pain syndrome.  The etiology, diagnosis and management are discussed in this Mayo Clinic review. The possibility should be considered in all anesthesia and critically ill patients, and appropriate steroid supplementation instituted.

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Cardiac Risk Prediction

A retrospective observational study compared well established cardiac risk prediction models: (i)the Revised Cardiac Risk Index, (ii)American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, and (iii)the Myocardial Infarction or Cardiac Arrest calculator.

While agreement was better between the latter two (ACS NSQIP and MICA), there was 30% discordance between assigning high or low risk compared to the RCRI.

The NSQIP certainly seems more modern and comprehensive than the RCRI but the divergence in risk assessment certainly needs to be borne in mind.

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Pre-operative Opiod Use and Characteristics

23% of this group reported pre-operative opioid use. “Age, tobacco use, illicit drug use, higher pain severity, depression, higher Fibromyalgia Survey scores, lower life satisfaction, and more medical comorbidities were independently associated with preoperative opioid use”. Use was highest in those presenting for orthopedic and neurosurgical procedures. This data may be important in pre-operative management, weaning or risk mitigation and peri-operative and post-discharge opioid prescribing.

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