Cesarean Prophylactic Phenylephrine

It has become common practice to start Phenylephrine infusions after spinal anesthesia for Cesarean to prevent hypotension and accompanying nausea. (Norepinephrine has more recently entered into this area [ link ] ). This study suggests possible unintended consequences in that the Bupivacaine dose for effective spinal anesthesia may be increased by prophylactic Phenylephrine infusion. The ED95 of intrathecal hyperbaric bupivacaine was 14.1 mg (95% CI, 12.3–37.6 mg) with prophylactic phenylephrine infusion and 11.7 mg (95% CI, 9.9–22.8 mg) in the control group.

link

 

Anti-Psychotics for Delirium

The use of anti-psychotics for critical illness delirium has been controversial with a trend towards lack of beneficial effect for treatment or prophylaxis.  This latest study shows: “The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium.”

Non-pharmacological management remains the ideal goal although some would still use as a last resort for patient or staff safety.

NEJM link

 

Bloodstream Infection and Decontamination Strategies

The use of oral chlorhexidine and other decontamination strategies in ventilated patients to prevent multi-drug resistant blood stream infections has been controversial.  This study again failed to find benefit, concluding: “Among ventilated patients in ICUs with moderate to high prevalence of antibiotic resistance, use of chlorhexidine 1% mouthwash, Selective Oral Decontamination , or Selective Digestive Tract Decontamination  was not associated with a significant difference in bloodstream infections with multidrug-resistant gram-negative bacteria compared with standard care”.

JAMA link

 

Aspirin for Thromboembolism Prophylaxis

“Aspirin alone may be an appropriate alternative to other pharmacologic prophylaxis in preventing VTE for patients undergoing total knee arthroplasty.”

So says this JAMA study but with the limitations of retrospective analysis and the subtleties of non-inferiority design. Nonetheless it adds to the debate and evidence on the use of aspirin alone as a potential strategy (which would also simplify neuraxial anesthesia concerns with anticoagulation).

link

 

Perioperative Acute Kidney Injury

An update article surveys the complex interplay of factors affecting kidney function in the perioperative period, discussing hemodynamics, fluids, diuretics, serum markers etc. “The Kidney Disease: Improving Global Outcomes guidelines suggest implementing preventive strategies in high-risk patients, which include optimization of hemodynamics, restoration of the circulating volume, institution of functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia.”

full text link

Another study links intraoperative oliguria to acute kidney injury, in contrast to previous work. This presents a conundrum in an ERAS era of restrictive fluid administration. Oliguria should should at least direct closer monitoring of renal function especially in those with risk factors, along with minimizing nephrotoxic sgents.

link

 

Weekly Medical and Health News

HPV vaccine fear-mongering dealt a blow – no increase in risky behaviours after vaccination  link

Rivaroxaban approved for reducing cardiovascular risks in coronary artery or peripheral vascular disease  link

Medicinal cannabinoids offer limited benefit in Multiple Sclerosis. But cannabis thrives on hype rather than evidence!   link

Cannabis becomes legal in Canada link

Acute flaccid paralysis, or myelitis, affecting many US children in polio-like illness  link

Aspirin use in healthy elderly persons did not prolong disability-free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo  link

Cannabis and tobacco products frequent in hip-hop music videos, and may be negatively influencing youths  link

Major cardiac stem cell paper retraction from Harvard and Brigham and Women’s  due to falsified and/or fabricated papers from Dr. Anversa  link

Potential link between cannabis and stroke presented  link

Most older people open to reducing number of medications and de-prescribing  link

Tamoxifen in early breast cancer increases risk of thromboembolism  link

High urate levels that often precede gout are more genetic based than dietary  link