Diclofenac cardiovascular risks

All NSAIDs have been linked to increased cardiac risks but this BMJ review singles next out Diclofenac (eg. Voltaren) as the worst agent. “The incidence rate ratio of major adverse cardiovascular events at 30 days among diclofenac initiators increased by 50% versus non-initiators, by 20% versus ibuprofen or paracetamol initiators, and by 30% versus naproxen initiator”.

Adverse events included atrial fibrillation or flutter, ischaemic stroke, heart failure, myocardial infarction, and cardiac death; both sexes of all ages; and even at low doses of diclofenac.

Risk of upper gastrointestinal bleeding at 30 days with diclofenac was similar to that of naproxen, but much higher than for no NSAID initiation, paracetamol, and ibuprofen.

Encountering such patients in the pre-admission setting is an opportunity for counselling and risk mitigation.

Peripheral nerve blockade in diabetic neuropathy

This study found that after ultrasound‐guided popliteal sciatic nerve block, patients with diabetic peripheral neuropathy had a reduced time to onset of sensory blockade, with increased time to first opioid request when compared with patients without neuropathy. 30 ml 1:1 mixture of lidocaine 1% and bupivacaine 0.5% was used

Concern has existed that patients with peripheral neuropathy have increased sensitivity as well as nerve injury risk from local anesthetics. The “double crush” hypothesis of already ischemic/hypoxia nerves suffering more injury from needles or local anesthesia has been a concern although not totally proven; this study was not powered to make such a conclusion. However, it may guide dose selection for peripheral nerve blocks in this population.

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Transfusion in Pediatric ARDS

The Pediatric Critical Care Transfusion and Anemia Expertise Initiative issues consensus recommendations on red cell transfusion in critically ill pediatric ARDS. The guidelines are in keeping with the widespread trend of restrictive blood policies.

“Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/d”.

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Adverse side effects of dexamethasone in surgical patients

A single dose of Dexamethasone is widely used in anesthesia as an anti-emetic. This Cochrane review sought to assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients.

They found a single dose of Dexamethasone did not increase infection within 30 days. The data was inconclusive on wound healing, and there was some increase in blood sugar. They caution on extrapolating such data where infection and wound healing may be more likely, such as diabetes or immunodeficiency. Also the surgeries were very heterogeneous, including cardiac, abdominal, neurosurgery, orthopedic etc. and no differentiation is mentioned between elective and emergency surgery. Further studies are awaited.

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Lidocaine for Anesthesia-Related Cough

While Lidocaine has been demoted in ACLS and cardiology, it has enjoyed a renaissance in Anesthesia and Pain Medicine. Intravenous bolus and infusion are being used in opioid-sparing anesthesia and to speed recovery of bowel function and provide analgesia ( link ).

This meta-analysis and review may provide another rationale for its use in anesthesia. Some caution is in order especially for those at risk of cardiac or systemic toxicity, as reports of adverse effects are sparse. It is important to co-ordinate with the surgeon to guard against concurrent local anesthesia infiltration or epidural/nerve blocks that could risk such toxicity.

‘The conclusion: Within a range of 0.5–2 mg·kg−1, intravenous lidocaine dose-dependently prevents intubation-, extubation-, and opioid-induced cough in adults and children with NNTs ranging from 8 to 3. The risk of harm in high-risk patients remains unknown.

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Agitation in adults in the post-anaesthesia care unit

This analysis studied factors associated with agitation after general anesthesia in adults:

Substance use disorder, cognitive impairment, psychiatric conditions, obesity, fall risk, presence of indwelling tracheal tubes/NG tubes/chest tubes/urinary catheters.

Such factors could help plan and allocate staff and resources to the post-anesthesia care unit to optimize patient safety.

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Analgesic index using nasal photoplethysmography

Commercial analgesic indices exist in clinical settings to quantify acute pain objectively. The Surgical Pleth Index from GE uses photoplethysmography from an index finger, and is more accurate than conventional hemodynamic indices; it measures the change in the volume of arterial blood with each pulse beat – pain stimulation reduces photoplethysmographic amplitude and heart beat interval. It’s accuracy and usefulness are reported as variable.

This study used nasal photoplethysmography between the nasal septum and columella, postulating less interference and susceptibility to perfusion issues. It found that using diastolic peak point variation and heart beat interval variation resulted in greater accuracy than the Surgical Pleth Index. The measurements took place in the recovery period, and they plan further studies to assess its usefulness during general anesthesia, although it is unclear what pain (without the subjective experience) means under anesthesia – rather it is nociception, and how that may impact outcome or chronic pain remain to be seen

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Prothrombin Complex Concentrates For Vitamin K Antagonist Reversal

The following figures emerge from this Anesthesiology review: Annual rates of major hemorrhagic events ranged from 1.0 to 7.4% in a systematic review of patients with atrial fibrillation receiving vitamin K antagonist therapy, while rates of intracranial hemorrhage in the same population ranged from 0.1 to 2.5%. Major bleeding occurred in 3.3% of warfarin-treated patients undergoing elective surgery, but 21.6% in patients in emergency surgery

Fresh Frozen Plasma brings risks of fluid overload, lung injury, infection and is slow to act and less effective. Vitamin K alone is feasible only when surgery can be delayed 24-48 hours.

Current guidelines recommend prothrombin complex concentrates (PCC), specifically four-factor prothrombin complex concentrates, with concomitant intravenous vitamin K, as the preferred therapy for urgent vitamin K antagonist reversal, which are effective in 30 minutes or so. PCCs reduces bleeding and some studies suggest mortality also. Many studies show them to be more effective than FVIIa. Thromboembolism has not been found to be increased to date.

Whereas specific reversal agents are in use or being introduced for Factor Xa Inhibitors and Direct Thrombin Inhibitors, PCCs may be worth considering for hemorrhage in such patients in the interim although their efficacy is very variable for non-vitamin K antagonist reversal.

The full review surveys all the published studies and also examines evidence in various scenarios such as intracranial hemorrhage, cardiac surgery and trauma.

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