Laparoscopic Cholecystectomy Pain

A ‘PROSPECT’ review of laparoscopic cholecystectomy pain makes the following procedure specific recommendations.

Acetaminophen (Paracetamol) + NSAIDs or CoX-2 Inhibitors + site local anesthetic infiltration.

They do not in general recommend TAP blocks, intra-peritoneal local anesthetic or gabapentinoids. Opioids are reserved for rescue analgesia.

They recommend low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum. Single-port incision techniques are not recommended to reduce pain.

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Pediatric Regional Anesthesia Complications

A somewhat reassuring study on pediatric anesthesia regional anesthesia that included both peripheral nerve and neuraxial blocks finds: “In a prospective multicenter cohort of more than 100,000 blocks in children, there were no cases of permanent neurologic deficit associated with regional anesthesia. The rate of transient neurologic deficit was low at 2.4 per 10,000, and the incidence of local anesthesia toxicity was also low at 0.76 per 10,000”.

There was only one epidural abscess, and one epidural hematoma in a paravertebral block. Transient neurological deficits did not differ between peripheral and neuraxial blocks. Importantly, no additional risk was observed with placing blocks under general anesthesia.

The most common adverse events were benign catheter-related failures (4%).

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Benzodiazepines & Neuropsychiatric ICU Outcomes

Benzodiazepines are increasingly falling out of favour as sedation agents in ICU because of their association with delirium in particular. Dexmedetomidine on the other hand is finding favour because of better outcomes in that regard.

This systematic review concludes: “The majority of included studies indicated that benzodiazepine use in the ICU is associated with delirium, symptoms of posttraumatic stress disorder, anxiety, depression, and cognitive dysfunction. Future well-designed studies and randomized controlled trials are necessary to rule out confounding by indication”.

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Continuous Non-Invasive Blood Pressure

Continuous non-invasive blood pressure monitoring from finger cuffs is possible with a number of devices. Adoption has been slow due to clinician wariness and validation concerns. This study assessed hypotension less than 65mm mean arterial pressure as compared to 3 minute standard arm cuff measurement in non-cardiac surgery.

“Continuous noninvasive hemodynamic monitoring nearly halved the amount of intraoperative hypotension. Hypotension reduction with continuous monitoring, while statistically significant, is currently of uncertain clinical importance”

There certainly is a wealth of evidence on the harms of even short duration hypotension on the heart and kidneys but whether this mode of monitonring can impact clinically meaningful outcomes remains to be seen.

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Medical News Weekly

EpiPen shortage in Canada continues link

Deadly Ebola virus returns in DRC  link

Mulpleta approved for surgery in liver disease to boost platelets  link

Drinking while breastfeeding can affect child’s cognition  link

Beware “vaginal rejuvenation” procedures!  link

Pathogens now even becoming resistant to alcohol based hand sanitation  link

Kids gluten free foods may be less healthful link

Rifampin for four months may be a better choice than nine months Isoniazid for latent TB in adults  link

– and also in children link

Should LDL cholesterol be lowered even more?  link

Depo-Medrol should not be used in epidurals. link

 

Acute Kidney Injury, Fluids and Norepinephrine

Norepinephrine is being used to help limit excessive fluid administration in keeping with current enhanced recovery protocols. This study shows that while this agent was not harmful, too restrictive an approach to administration of crystalloids was associated with an increased risk for AKI, particularly in older patients, those receiving antihypertensive medication, and those whose surgery was prolonged. Perhaps “modestly liberal” is the best again as in the Relief trial blog link

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Lidocaine & Colonoscopy

DIfferent sedation regimes are used for colonoscopy – Midazolam/Fentanyl or Propofol most commonly, or combinations thereof. Some, as in this study, use Propofol and low dose Ketamine combination. However they added Lidocaine 1.5 mg kg−1 then 4 mg kg−1 per hour. This reduced the amount of Propofol required. “Intravenous infusion of lidocaine resulted in a 50% reduction in propofol dose requirements during colonoscopy. Immediate post-colonoscopy pain and fatigue were also improved by lidocaine“. Some find Lidocaine IV helps gagging during gastroduodenoscopy  also, bearing in mind any dose used topically.

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