Duration and Type of Surgical Prophylaxis and Adverse Events

While retrospective in nature, this study appears to confirm that antibiotic prophylaxis should not be unduly extended after surgery, as complications increase after 24 hours. Higher kidney injury rates occur with Vancomycin also.

Increasing duration of antimicrobial prophylaxis was associated with higher odds of acute kidney injury (AKI) and C difficile infection in a duration-dependent fashion; extended duration did not lead to additional surgical site infection (SSI) reduction. “These findings highlight the notion that every day matters and suggest that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI”.

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Preoperative Carbohydrate Loading

Pre-operative carbohydrate loading has been shown to reduce pre-operative discomfort and postoperative nausea and vomiting in general surgical patients, and is a component of enhanced recovery after surgery (ERAS) protocols. This study considered day-case surgery, specifically day case cholecystectomy.

The carbohydrate-rich drink group received oral carbohydrate (200 ml) 2 to 3 h before surgery, and the control (fasting) group fasted from midnight according to standard protocol.

There were no significant differences in any VAS scores between the study groups. No differences in time to mobilisation, need for pain or antiemetic medication or time to discharge were seen between the groups.

The authors conclude: compared with overnight fasting, pre-operative carbohydrate loading did not significantly enhance peri-operative well being or recovery in patients undergoing day-case cholecystectomy.

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Deep Neuromuscular Block and Surgical Conditions

Two studies on the potential benefits of deeper neuromuscular block during laparoscopic surgery produce somewhat different results.

The first finds: Switching from moderate to deep block improves surgical conditions. Poor surgical conditions were associated with a higher incidence of surgical complications.

The second finds: Continuous rocuronium infusion did not improve surgical conditions when boluses of rocuronium were available on-demand. No major benefits in other outcomes were seen.

The debate continues…

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Ventilation in patients with intra-abdominal hypertension

A full text review on ventilation in intra-abdominal hypertension.

Intra-abdominal hypertension (IAH) is defined as a sustained increase in intra-abdominal pressure (IAP) equal to or above 12 mmHg. IAH affects the brain, the cardiovascular system and the lungs.

The average incidence of IAH in critically ill patients is around 25–30% on admission, and the cumulative incidence is around 50% during the first week of ICU stay. There is an association between IAH and respiratory failure.

IAH is associated with a decrease in lung volumes, a decrease in chest wall compliance, and abdomino-thoracic pressure transmission, while decompressive laparotomy results in an improvement in lung volumes.

The presence of IAH affects lymphatic drainage between the thoracic and abdominal cavity and may play an important role in the development of edema formation.

The article discusses recruitment maneuvers, PEEP, protective lung ventilation, prone positioning, hemodynamic changes, and the Abdominal Compartment Society guidelines for managing IAH or abdominal compartment syndrome.

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QI Program to improve survival – EPOCH trial

This study examined the effectiveness of a national quality improvement (QI) programme in the UK to implement a care pathway to improve survival in emergency abdominal surgery.

The conclusions were not positive!

“No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care”.

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i-gel® insertion and cricothyroid membrane identification

This small study examined cricothyroid membrane identification in adult females, whose anatomy is less pronounced than males. They concluded:

“The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy”.

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Lymphedema Risk And IV Placement

Recently reposted by the APSF, post-mastectomy lymphedema is a burdensome and sometimes intractable risk that has led to the advice to avoid all intravenous placements and blood pressure recording on the involved side.

Although some evidence has deemed it is acceptable practice, the response in this article emphasizes that the risk of lymphedema is lifelong and they condone taking all risk reduction measures to mitigate against the potential. Therefore it seems prudent to continue avoiding the mastectomy side limb unless circumstances dictate the risk is acceptable, eg. an emergency.

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Medical and health news weekly

Electrical brain stimulation is first approved device for ADHD link

Increasing muscle power even better than strength for prolonging life link

Measles in the US surges to a record number of cases as a result of anti-vaccination quackery link

Rejecting vaccination is a major public health issue as half a million UK children miss measles vaccination link

And quarantine in LA universities because of (yes) measles link

Generic Naloxone nasal spray for opioid overdose approved in US for use by untrained people link

Quitting cigarettes before or in early pregnancy reduces preterm birth link

Soft bedding, prone position, overlay, and wedging still causing infant deaths link

Skipping breakfast again associated with cardiovascular mortality link

Screen time associated with inattention and ADHD symptoms in pre-schoolers link

With the opioid crisis and opioid-phobia, some doctors have misapplied guidelines, cutting off effective pain relief for some patients link

Another infant sleeper recalled link