ACE Inhibitors and ARBS before Non-cardiac Surgery

There are well described cardiovascular benefits with the use of ACE Inhibitors and ARBs but many anesthesiologist withold them prior to non-cardiac surgery due to reports of refractory hypotension. Recent studies have been more reassuring and this meta-analysis “did not demonstrate an association between perioperative administration of ACE-I/ARB and mortality or major adverse cardiac events.  It did however confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intraoperative hypotension”. The clinical significance is unclear and controversy is likely to continue on the potential harms vs. benefits, and individualized decisions may be necessary based on the type and magnitude of surgery. At any rate, recommencing these agents is advised as soon as practicable.

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Lidocaine during Surgery and Quality of Recovery

The use of intravenous Lidocaine as an analgesic and as an adjunct during anesthesia is growing. This study focussed on other aspects of quality of recovery, and found improvements also in areas like emotional state, physical comfort, as well as pain. They used thyroid surgery as their subjects suggesting the benefits of Lidocaine are not confined to bowel surgery recovery. One group received Magnesium for comparison and the effects were not significantly better.

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Steroids and sepsis

The perennial topic of sepsis and septic shock get another review in this article. The conclusions in the ADRENAL and APROCCHSS trials were somewhat at odds and the bottom line in this review is there may be a slight improvement in mortality but the effect is small if any. Steroids may also increase risk of neuromuscular weakness.

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Medical News Weekly

About 1 in 10 women with post-menopausal bleeding have endometrial cancer link

More Choosing Wisely family practice guidelines link

Pre-emptive TIPS in high risk variceal bleeding improves outcome link

Vaping may be more harmful than many believe. It affects immune cells and boosts inflammation  link

Universal screening for urinary incontinence in women?   link

Exercise is good for mental health, just how much is enough?  link

Sudden infant sleep related deaths not declining and more focus on the issue needed  link

Quitting smoking and gaining weight may temporarily increase diabetes risk but reduces overall and cardiovascular mortality. So quit!  link

In contrast to other study suggestions, maternal vitamin D supplementation from midpregnancy until birth or until 6 months post partum did not improve fetal or infant growth link

The poly pill combo: in a Sri Lankan setting,  treatment with a pill containing low doses of 3 antihypertensive drugs led to an increased proportion of patients achieving their target BP goal  link

Traumatic brain injury may be associated with increased risk of suicide  link

Although observational and questionnaire based, study finds low carb diets fare worse for mortality unless the extra protein and fats are plant based link

Removing the cancer label from low risk conditions that are unlikely to cause harm if left untreated…  link

 

Pediatric and Neonatal Airway Management

Issues of concern in the area of Pediatric and Neonatal ICU in airway management are highlighted in the UK in this survey study.

Compared with adult ICU, there was less airway policies, difficult airway carts, checklists, videolaryngoscopy and way less capnography. This was more pronounced in the Neonatal area.

The authors conclude “major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units“.

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Pain, Agitation/Sedation, Delirium, Immobility, and Sleep In ICU

Updated Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

The role of immobility and sleep are new as is patient involvement. Benzodiazepines are definitely out of fashion in favour of Dexmedetomidine and Propofol. The full executive summary is not long and every critical care physician needs to read it.

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Remifentanil PCA for Labor Analgesia

Epidural rates were significantly reduced in those receiving remifentanil PCA compared to im meperidine (pethidine). The PCA regime was 40mcg with a 2 minute lockout vs. im meperidine 100mg q4h prn.

The use of meperidine as a standard of care is dated. Many studies have not found Remifentanil to be entirely safe in terms of respiratory risk although this study showed no difference.

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Hyperoxia and Pediatric ICU Mortality

In this single-center retrospective study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. The retrospective nature makes many confounding variables enter the equation and correlation does not imply causation but the dangers of hyperoxia in many settings make this study important

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This blog has a collection of hyperoxia adverse outcome studies in many settings blog link