Procedural Sedation

A recent guideline from the American College of Emergency Physicians on unscheduled procedural sedation is interesting to compare with  American Society of Anesthesiologists’ views on sedation. There have been longstanding tensions between the ASA and others who administer sedation such as gastroenterologists and dentists.

The ACEP take the view that the proceduralist can give or direct giving sedation and that the level of responsiveness and ventilation are more important than the agent used (clearing the way for Propofol!). Skills are needed to rescue a patient who slips into deep sedation or general anesthesia.

The risk of gastric aspiration so central to Anesthesia practice is downplayed with reasonable evidence of how rare an occurrence it is, an issue sure to provoke controversy.

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Time of Day and Emergency Surgery Mortality

Some studies have suggested worse outcomes and higher mortality in surgery after hours and in particular at weekends, although others did not corroborate  (see ‘weekend effect’ link ). One of the postulated mechanisms is fewer resources, staff and backup.

This single center study was in emergency surgery and did not identify an association of time of emergency surgery, categorised into one of three epochs (day, evening and night) with death up to 30 postoperative days. They do advise further larger studies with longer follow up to verify these findings. A large and sometimes disparate mix of emergencies including general, neuro, Cesarean under regional and sedation-only was studied  with minimal comorbidity information other than ASA status.

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ECMO for Cardiac Arrest

Refractory cardiac arrest was defined as no return of spontaneous circulation after 30mins of CPR.

This was a small observational study of 23 patients suffering cardiac arrest in the Operating Room who underwent extracorporeal cardiopulmonary resuscitation. The survival rates of neurologically‐intact subjects were 9/23 (39%) and 6/23 (26%) at 24 hours postoperatively and at hospital discharge, respectively.The main cause was hemorrhagic shock and 23% of these were discharged neurologically intact.

Where available, extracorporeal cardiopulmonary resuscitation is suggested as an option for refractory cardiac arrest in the OR due to hemorrhage.

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Medical and Health News Weekly

German nurse was a prolific serial killer  link

Ultrasound ovarian cancer screening does not reduce mortality in average risk women, despite what Ellen show celebrity guests say  link

Oral curcumin (turmeric) shows no anti inflammatory or other benefits in elective abdominal aortic aneurysm surgery link

Air pollution is a serious health threat and world killer link

Bowel cancer increasing in young, obesity one potential mechanism link

Lavender really has anti-anxiety properties  link

There are no limits to how beneficial exercise is for mortality link

Memory and cognitive function in adolescents improves after cannabis abstinence link

Obesity linked to higher all-cause mortality; low BMI also linked to mortality but in a less clear fashion  link

Some researchers believe Parkinsons linked to gut, appendix in particular  link

Minimally invasive radical hysterectomy was surprisingly associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer  link

Older fathers (> 45 years old) linked to higher gestational diabetes, prematurity, low birth weight and infant seizures link

 

Totally intravenous anesthesia guidelines (TIVA)

Total intravenous anaesthesia is mandatory far malignant hyperthermia, and is also commonly used for airway surgery, anaesthesia outside the operating room and during transport.  It also possesses advantages for those with a history of nausea and vomiting, or allowing measurement of evoked potentials.

These novel consensus guidelines from the UK & Ireland encompass all theoretical and practical aspects, in  particular the use of Propofol and Remifentanil.  They recommend target controlled infusion (not available everywhere). Allowance must be made for the pharmacokinetic models when concomitant agents are used, or in the elderly or sick/frail and obese. Remifentanil infusion has been linked to acute tolerance and opioid induced hyperalgesia.

Suggested doses are given, as well as cautions with pump and tubing setup. Awareness risk is especially important, and where neuromuscular blocking agents are used, processed EEG monitoring is recommended.

The link provides an excellent introduction and overview:

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Cervical Cancer Survival and Minimally Invasive Surgery

Minimally invasive surgery has been promoted as part of enhanced recovery after surgery protocols (ERAS) but a rather surprising finding in early cervical cancer finds that minimally invasive radical hysterectomy was  associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer.

Confounding, surgical, operator experience factors are among possibilities but further studies are required to explain these findings.

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BP, CO2 during Aneurysm Occlusion and Outcome

Comtrol of Blood Pressure and end tidal Carbon Dioxide has been of importance in certain neurological injuries. This retrospective study of subarachnoid aneurysm occlusion (surgery or coiling) showed that there were no clinically important or statistical significant associations between either end-tidal carbon dioxide or mean arterial pressure thresholds and Glasgow Outcome Scale at discharge or three months. Other prognostic factors may be more important.

The data show that adherence to current standards of practice largely occurred so there were only rare extreme deviations, therefore it is not that CO2 or BP are unimportant but some deviations may not be of great importance.

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Cricoid Pressure Alternative

Cricoid Pressure has been a controversial practice as illustrated by this recent study casting doubt on it: link

It continues to be analyzed due to conflicting views on its effectiveness, interference with placing tubes, and lack of true Level-1 evidence. This latest study uses the technique of ultrasound to assess gastric insufflation during mask ventilation and found that the more effective technique was left paratracheal  compression just above the clavicle and between trachea and sternocleidomastoid muscle, using the thumb when performed manually.

Several caveats are advised: entry of air into the stomach is not synonymous with aspiration of gastric contents, a maximum pressure of 25cm H2O was used, it may not be extrapolated to anesthesia or with the use of neuromuscular blocking agents or obese patients.

As always, further studies are needed before it becomes practice changing…

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TIVA vs. Inhalational Anesthesia for Breast Cancer

A previous retrospective study suggested that total intravenous anesthesia (TIVA) led to better cancer outcome in colon cancer surgery ( link ).

This current study is also retrospective in breast cancer recurrence but does not replicate the previous findings in that there was no difference in breast cancer survival with TIVA or inhalational anesthesia.

These retrospective designs make firm conclusions impossible for now in how anesthesia type may influence cancer prognosis and further studies are needed.

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Discontinuing Long-term Opioids in Chronic Pain

Judicious weaning and even discontinuing long term opioids in chronic pain is an option to discuss with patients. Whereas pain may not be fully controllable, quality of life is just as important and that includes the potential harms of opioids – addiction, overdose and death, falls, fractures, constipation, reduced libido, infertility, osteoporosis, sleep-disordered breathing, depression and motor vehicle accidents (link)

This retrospective review suggests that pain is no worse after discontinuing long term opioids especially in mild or moderate pain and may in fact slightly improve. Mechanisms involved may include tolerance and/or hyperalgesia.  The authors caution that nonetheless such patients may remain at risk for mental illness or suicide and careful psychosocial follow up is mandatory, as well as multimodal pain management strategies including non-pharmacological methods.

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