Mannitol in Critical Care

Mannitol has a long history of use to decrease intracranial pressure in neurosurgery and traumatic brain injury but it’s effect on long term outcome is still uncertain.

This free full text review – a meta-analysis and systematic review – surveys its history and usage. Its conclusion is essentially:

“Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.”

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

This study assessed the value of commonly used predictors of fitness for extubation in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Their conclusions:

“Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.”

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Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis

This retrospective study surveyed general vs. spinal anesthesia for infants with pyloric stenosis. While it may not be in the comfort zone for some practitioners, it was shown that it was a viable alternative to general anesthesia, reducing the respiratory morbidity associated with the latter, significantly reducing apneic episodes and desaturation.

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Music versus midazolam during preoperative nerve block placements

The essential conclusion in this study was the equivalence between music played through noise cancelling headphones and Midazolam.

While previous evidence has suggested the utility of music for awake patients, it should be noted that physician satisfaction was higher than patient satisfaction. And both judged communication to be more impaired in the music group.

Nonetheless sedation has gone s little out of fashion in both anesthesia and ICU with links to delirium in many studies in the elderly and substitution with music may be worth considering.

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Stillbirth linked to more childbirth complications

A commentary on a journal study showing life-threatening delivery complications are more than four times as common during and after a stillbirth than a live birth. Some of these complications are more than 10 times as likely with stillbirths, per this Stanford study.

Complications included sepsis and shock, renal failure and cardiac problems. Certain causes if stillbirth like infection or hypertensive diseases were strongly linked to delivery complications for the mother.

This highlights another area to continuously improve maternal care, California also previously making important quality strides in maternal care improvement.

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Dexmedetomidine + Propofol for Colonoscopy?

Numerous adjuvants to Propofol have been used for colonoscopy sedation, such as Midazolam or more recently Ketamine or Lidocaine. This study supports Propofol as a sole agent.

Combining a low dose of dexmedetomidine with propofol decreased propofol consumption in adults having ambulatory colonoscopy, with no increase in sustained bradycardia. However, using only propofol for colonoscopy provided more stable hemodynamics, faster recovery from anesthesia, and faster attainment of discharge readiness, compared with using propofol–dexmedetomidine.

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Haloperidol and Long Term ICU Outcome

This study examined the use of prophylactic Haloperidol in ICU patients at high risk of delirium. While it is often a treatment agent used when non-pharmacological approaches to delirium fail, this study confirms that prophylactic use exerts no beneficial effect on long-term quality of life in ICU survivors.

The REDUCE study previously showed that neither does it reduce the incidence or duration of delirium.

“The factors age, medical, and trauma admission, baseline quality of life, risk for delirium, and the number of sedation-induced coma days are associated with the decline in long-term outcome parameters.”

And a major message is “Every additional day of sedation-induced coma is associated with further decline of long-term physical and mental function”.

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Spinal Anesthesia Failure

This retrospective study analyzed the factors associated with spinal anesthesia failure in patients undergoing elective total hip or knee arthroplasty.

The factors associated with increased odds of spinal failure included younger age, lower BMI, hip arthroplasty vs. knee arthroplasty, needle insertion at L4-5 and L5-S1 vs. L2-3, 22-gauge needle size vs. 25-gauge needle, and hyperbaric bupivacaine vs. isobaric bupivacaine.

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Driving Pressure and Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome

Driving pressure is the difference between plateau pressure and positive end-expiratory pressure (PEEP), and is known to be associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). This has been demonstrated in controlled mechanical ventilation.

This study viewed it in the spontaneous ventilation/ weaning scenario. They established driving pressure and compliance could be reliably measured and an important finding that “Higher driving pressure measured during pressure support (assisted) ventilation significantly associates with increased intensive care unit mortality, whereas peak inspiratory pressure does not.”

Lower respiratory system compliance also significantly associates with increased intensive care unit mortality.

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Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty

This large national cohort “identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.”

Benzodiazepines and gabapentinoids were associated with higher odds of delirium, whereas lower risk of delirium was associated with neuraxial vs. general anesthesia, use of NSAIDs and COX2 Inhibitors, and high vs low opioid use specifically in the over 65 year olds.

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