Methylprednisolone for AKI in Cardiac Surgery

A sub study of a randomized trial finds: “Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery”.

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A previous review casts doubt on the use of steroids for various purposes in cardiac surgery, finding that they had “an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect”. link

Aluminum Release by Fluid Warmers

Many fluid and blood warming devices exist. Some use disposable aluminum (aluminium) coated plates in their cartridges; these may be coated or uncoated, the latter allowing the fluid to be in direct contact with the heated aluminum plate.

This study compared the two systems. They found that uncoated aluminium plates in an enFlow warmer can lead to a risk of administering potentially harmful concentrations of aluminium when balanced crystalloid solutions are used; by contrast, normal saline showed only small increases. The mechanism is unclear, but heat, low flow and longer infusion caused striking increases in Aluminum release.

Aluminum has been linked to neurological injury (especially in neonates), encephalopathy, osteomalacia, and renal injury.

Coating for aluminium within medical devices in direct contact with infusion fluids is recommended, but further studies on what implications these findings have for health and safety are needed.

Many hospitals have withdrawn the devices for now.

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Medical and Health News Weekly

Delayed antibiotics for UTIs in the elderly increases blood stream infection and mortality link

Robotic surgery warning – not approved for cancer surgery link

Combining Aspirin and anticoagulants increases bleeding risk; many taking Aspirin for no clear indication link

Stem cell transplant patient ‘free’ of HIV; too early to say ‘cured’ link

A Danish study looks at MMR vaccination in nearly 700,000 kids, including so-called susceptible ones – there is no link to autism! link

Professional soccer players are twice as likely to develop ALS and 2 decades earlier link

Amid criticism, Eli Lilly to sell cheaper generic Humalog Insulin in US only – for a mere US$137 per vial (while Canadians complain of having to pay $25!) link

Post menopausal systemic hormone replacement linked to slightly higher Alzheimer’s risk (but not with vaginal estradiol). Previous studies show its safe when begun early and in those less than 60. Case control study that shouldn’t in general cause alarm link

Raw meat food for dogs has lots of bacteria that can make you ill when the good boy licks you! link

Dexamethasone in Surgical Patients

Dexamethasone use as an anti-emetic has become near universal in anesthesia practice. This systematic review sought to ascertain whether it causes adverse side-effects.

The primary outcomes were postoperative systemic or wound infection, delayed wound healing and glycemic response within 24 h.

No link to wound infections was found, while it was unclear whether it affected wound healing. Mild increases in glucose within 12 hours occurred (mean difference 0.7mmol/L).

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Delirium in Older Acute Care Surgery

Patients older than 65 years were followed after acute care surgery. Some 23% had delirium from a validated chart review.

Postoperative delirium risk factors included Foley catheter use, intestinal surgery, gallbladder surgery, appendix surgery, intensive care unit admission and mild to moderate frailty. Risk factors for prolonged postoperative delirium (> 48 hours) included Foley catheter use and mild to moderate frailty. Surgical approach (open v. laparoscopic) and overall operative time were not found to be significant.

The seemingly innocuous Foley urinary catheter consistently appears as a delirium risk factor and protocols to ask every day whether it can be removed are appropriate.

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Anesthesia and Cancer Outcome

Another meta-analysis reflecting ongoing interest in inhalational vs. total intravenous anesthesia (TIVA) and cancer outcomes.

The use of TIVA was associated with improved recurrence-free as well as overall survival in all cancer types. It was especially evident where major cancer surgery was undertaken. Breast surgery was studied most extensively.

Most studies were retrospective, with varying follow-up, demographic variations, population imbalance, cancer grade/stage differences, different surgery magnitude, and other anesthetic technique differences. It is therefore necessary to be cautious about the findings and wait for larger randomized studies to confirm what could be a major finding in favour of Propofol-based TIVA.

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Vitamin C and ICU Outcome

Vitamin C as a panacea has been an especially persistent philosophy. Cocktails along with Thiamine and Hydrocortisone are being investigated (and hyped) for sepsis, but there is no robust evidence to support the practice at this point.

This systematic review and meta-analysis of a mixed critically ill population finds no significant effect on acute kidney injury, survival, length of ICU or hospital stay. In cardiac surgery, beneficial effects on postoperative atrial fibrillation, ICU or hospital length of stay remain unclear.

Clearly further studies are needed before Vitamin C alone or as part of a cocktail can be recommended for critically ill patients.

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Medical Cannabinoids Systematic Review

Yet another review weighs in to dispel hype and marketing from the huge cannabis industry.

The conclusion is: There is reasonable evidence that cannabinoids improve nausea and vomiting after chemotherapy. They might improve spasticity (primarily in multiple sclerosis). There is some uncertainty about whether cannabinoids improve pain, but if they do, it is neuropathic pain and the benefit is likely small. Adverse effects are very common, meaning benefits would need to be considerable to warrant trials of therapy.

No matter, the anecdotal based evidence will continue to be pushed by vested interests.

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Early Use of Norepinephrine in Septic Shock Resuscitation

The CENSER randomized trial is a single center study comparing early Norepinephrine with standard care in septic shock.

The primary outcome was shock control rate (defined as achievement of mean arterial blood pressure >65mmHg, with urine flow >0.5mL/kg/h for 2 consecutive hours, or decreased serum lactate >10% from baseline) by 6 hours after diagnosis.

Early Norepinephrine use was associated with better shock control at 6 hours, less cardiogenic pulmonary edema, and fewer new arrhythmias.

However 28 day mortality was not different between the groups. More studies are needed before any practice change can occur; nonetheless recent Surviving Sepsis updates recommend that vasopressors can be commenced during or after volume resuscitation, acknowledging that not all patients may need 30mL/kg ( link )

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Pediatric Severe Traumatic Brain Injury Guidelines

These updated guidelines on brain trauma in infants, children and adolescents help in determining our approach to brain trauma. The article does note that while progress has been made, overall the level of evidence informing these guidelines remains low. There is a need for quality randomized trials. With that in mind, the guidelines and evidence level include:

Use of ICP monitoring suggested (III)

If brain tissue oxygenation (PbrO2) used, keep > 10 mm Hg (III)

Excluding elevated ICP from a normal initial (0–6 hr after injury) CT examination of the brain is not suggested in comatose pediatric patients (III)

Routine repeat CT scan after 24 hours is not suggested for decisions about neurosurgical intervention, unless there is either evidence of neurologic deterioration or increasing ICP (III)

ICP target < 20 mm Hg suggested (III)

CPP minimum target 40 mm Hg (40-50 suggested) (III)

Bolus Hypertonic Saline (HTS) (3%) is recommended for intracranial hypertension. Recommended 2 to 5 mL/kg over 10–20 minutes (II)

Continuous infusion HTS is suggested in patients with intracranial hypertension. Suggested 3% saline between 0.1 and 1.0 mL/kg of body weight per hour, administered on a sliding scale. The minimum dose needed to maintain ICP less than 20 mm Hg is suggested (III)

Bolus of 23.4% HTS is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a maximum of 30 mL (III)

Avoid bolus administration of midazolam and/or fentanyl during ICP crises due to risks of cerebral hypoperfusion (III)

Prophylactic seizure treatment is suggested to reduce the occurrence of early (within 7 d) seizures (III)

Hyperventilation to a PaCO2 less than 30 mm Hg in the initial 48 hours not recommended. If used for refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischemia is suggested (III)

Prophylactic moderate (32–33°C) hypothermia is not recommended over normothermia (II)

Moderate (32–33°C) hypothermia is suggested for ICP control, with slow rewarding 0.5-1° per 12 – 24 h (III)

High-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management (III)

Decompressive craniectomy (DC) is suggested to treat refractory neurologic deterioration, herniation, or intracranial hypertension (III)

Decompressive craniectomy is suggested to treat refractory neurologic deterioration, herniation, or refractory intracranial hypertension (III)

Use of an immune-modulating diet is not recommended (II)

Initiation of early enteral nutritional support (within 72 hr from injury) is suggested (III)

The use of corticosteroids is not suggested to improve outcome or reduce ICP (III)

Full evidence link