OSA and Opioid Prescribing

In surgical patients, a retrospective study showed a worrying rate of opioid prescribing (86%) at hospital discharge in patients with known or suspected Obstructive Sleep Apnea (OSA).

Such patients, many of whom are morbidly obese, are at increased risk of respiratory obstruction and depression, and guidelines (such as from the ASA) recommend closer monitoring as well as using multimodal non-opioid analgesia. Where opioid analgesia is required, the Society for Ambulatory Anesthesia advises against ambulatory surgery if pain control cannot be provided with predominantly non-opioid techniques in such patients. Even in-patients with OSA are frequently not properly monitored in high dependency units.

There is still clearly ample room for prescriber education in opioid risk evaluation and mitigation, and OSA patients are at special risk when discharged on opioids (and indeed even as in-patients).

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Enhanced Recovery Recommendations

The American Society for Enhanced Recovery releases a joint consensus on definition, management and prevention of postoperative gastrointestinal dysfunction.

It encapsulates many known protocols like low/no opioids, no NG tubes, minimally invasive surgery, Alvimopan where opioids are used, nausea/vomiting prophylactix, euvolemia and normal electrolyte balance, immediate eating and drinking, use of a combined isosmotic mechanical bowel preparation with oral antibiotics, and consider coffee/gum chewing.

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Tranexamic Acid and Intracerebral Hemorrhage

Tranexamic Acid has established a place for reducing bleeding in trauma, post partum, and in surgeries like orthopedic, neurosurgery, cardiac surgery.

The current trial in intracerebral bleeding found that while it decreased hematoma expansion and deaths by day 2 and 7, there was no difference in functional outcome at 90 days. There was no higher incidence of side effects like thromboembolism. The sample size can not rule out a beneficial effect in view of the early promising effects  and larger trials are needed.

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Health News

Warning on benzocaine in infants and children, common in teething products  link

Severe atopic eczema linked to increased cardiovascular risk  link

Potential for weight gain from antidepressants  link

S100B as a biomarker for mild traumatic brain injury in children may be useful as part of initial assessment and lower CT radiation link

Ebola outbreak in DRC  link

Eggs and Nutrition – the circus continues. They’re good for you this week – just enjoy and don’t read any more studies  link

Despite the new formulation of the nasal spray flu vaccine, AAP still recommends flu shot  link

IBD, specifically Ulcerative Colitis may increase later risk of Parkinson’s  link

FDA approves Aimovig monthly injection for migraine, a monoclonal antibody that studies so far have only shown to be better than placebo link

 

Norepinephrine Infusion for Cesarean Spinal Hypotension

Phenylephrine has become the favoured agent for hypotension during spinal anesthesia for Cesarean and studies show that using a continuous prophylactic infusion works best and also lowers nausea and vomiting. link

Norepinephrine is a similarly acting agent and studies are appearing showing its utility in preventing hypotension. “A manually titrated infusion of 5 µg/mL of norepinephrine was effective for maintaining BP and decreasing the incidence of hypotension, with no detectable detrimental effect on neonatal outcome”.

Some dose ideas are present in this study. But it may take time and more studies to be adopted by anesthesiologists more familiar with its ICU use, as well as direct comparison with current agents.

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ECMO for ARDS

A randomized study sought to answer the continuing debate over the utility of early extracorporeal membrane oxygenation for very severe ARDS.

“Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy“.

Bleeding and thrombocytopenia were higher in the ECMO group and ischemic stroke less.

There was a clear trend to better mortality but not clinically significant, and the trial was stopped early for futility. Experts question the statistical design and cutoff point for futility. There was also a sizeable crossover to rescue ECMO in the control conventional ventilation group. The debate is unlikely to end, and ECMO will probably remain in the armamentarium of severe ARDS treatment in expert centers as a viable choice.

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Extracorporeal Pediatric CPR

A small retrospective study of 56 Pediatric cardiac arrests (80% related to primary cardiac conditions), mean age 3.5 months (1-53).

Survival to hospital discharge was a very good c. 65%, best in younger age (3.5 months) and those with decreased extracorporeal CPR tones and those exposed to therapeutic hypothermia. Follow up showed a good quality of life and family functioning. Further studies are needed to establish whether the technique should be more widely available in Pediatric critical care.

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Anesthesia Neurotoxicity

The ongoing concern continues, albeit somewhat controversial, that general anesthesia may be neurotoxic. This observational study on over 60 year olds found elevated Neurofilament Light and Tau for 6 hours and remaining high at 48 hours after surgery. They are both markers of neuronal damage. Correlation with clinical outcome would require further studies but clearly the entire area of potential anesthesia neurotoxicity, particularly in the developing infant and toddler brain, as well as in the elderly, will remain an important sphere of research and concern.

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