Epidural Top-Ups in 2nd Stage Labor

The effect of top-ups in the second stage of labor was studied. Most women who received a top-up had a vaginal (spontaneous or assisted) delivery. Compared with women without a top-up, women requiring a top-up had more predictors of difficult labour and higher rates of assisted vaginal delivery and Cesarean delivery.

The need for top-ups may be a marker for difficult labor involving induction, augmentation, prolonged second stage etc.



Cell Salvage for Peri-Op Blood Conservation

Many strategies are important in minimizing blood transfusion during surgery, especially major surgery like cardiac, major (open) vascular, complex urology, obstetric and orthopaedic surgery. Important strategies include pre‐operative haemoglobin optimisation; bloodless surgery; the use of antifibrinolytics; blood conservation techniques; and evidence‐based transfusion triggers.

The current recommendations seek to widen availability and use of cell salvage where blood loss more than 10% of blood volume occurs. Whereas infection and cancer are not absolute contraindications, they recommend that the use of cell salvage in cancer surgery and infected fields should be considered on a case by case basis; leucodepletion filters should be used. Current evidence does not support the routine use of cell salvage during caesarean section.

Full review discussing the evidence, practice, risks and contraindications are in the review:


Whole Blood Resuscitation

Increasing interest is being reported in returning to whole blood rather than component transfusion in trauma. Much of the earlier experience comes from military studies, many of which are subject to selection or survivial biases and retrospective in nature. The overall evidence and rationale, as well as risk, is summarized in this review, with the usual scenario being a combination of whole blood with combination products. Further study is required to define what place whole blood transfusion may have in resuscitation.



SGLT2 Inhibitors and Peri-Op Ketoacidosis

SGLT2 Inhibitors are increasingly promoted for diabetes and this article again highlights the risks of euglycemic ketocacidosis. Fasting, hypovolemia, infection, surgery, bowel preparation, keto diets before bariatric procedures, excessive alcohol are some of the predisposing conditions. Treatment involve some aggressive rehydration and Potassium supplementation with Insulin infusion and sometimes bicarbonate. Prevention may necessitate withholding SGLT2 Inhibitors for up to three days, more than the recommended 24 hours.



ACEIs, ARBs and Post-Op Renal Injury

ACE Inhibitors and ARBs are commonly held before major non-cardiac surgery. This study showed that such practice did not prevent the development of post-op acute kidney injury. While the other rationale is to hold them to prevent severe or intractable hypotension, this may not be the mechanism causing acute kidney injury.



ARDS Guidelines

Updated guidelines based on current evidence from the UK Intensive Care Society on ARDS.


The British Thoracic Society supports the recommendations in this guideline.
Where mechanical ventilation is required, the use of low tidal volumes ( < 6 m l / k g ideal body weight) and airway pressures (plateau pressure < 30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio < 20kPa), prone positioning was recommended for at least 12 hours per day.
By contrast, high frequency oscillation is not recommended and it is suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure (PEEP) and the use of the neuro-muscular blocking agent cisatracurium for 48 hours was suggested for ARDS patients with PF ratios less than or equal to 27 and 20 kPa respectively.
Extra-corporeal membrane oxygenation (ECMO) was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extra-corporeal carbon dioxide removal (ECCOR).



Cannabis and Chronic Non-Cancer Pain


A study on cannabis dispels the hype again, finding no evidence that it reduces pain, improves outcome or reduces opioid use. “People who used cannabis had greater pain and lower self-efficacy in managing pain” – this is increasingly the key to managing (not eliminating) pain, using education, quality of life and function improvement rather than focus on pain.



LMA-S vs. i-Gel in Elderly

In paralyzed elderly patients both the LMA-S and i-gel were used successfully and safely. However, the i-gel demonstrated better airway sealing than the LMA-S at insertion and during maintenance of anaesthesia. Less manipulation at insertion and superior fiberoptic laryngoscopy grades were observed in the i-Gel group, and inspiratory pressures lower with higher leak pressures. The I-Gel’s simplicity without the need for cuff inflation make it an attractive option in ER settings also for the ‘occasional anesthesiologist’!



Remifentanil with Desflurane for LMA GA

While Sevoflurane is the standard agent for a non-irritating inhalational and spontaneously breathing anesthetic, the irritating effects of Desflurane  may be mitigated by the use of a Remifentanil infusion. This study showed that in the presence of a continuous infusion of remifentanil, desflurane is superior in terms of faster emergence and is similar in terms of intra-operative cough to sevoflurane or propofol infusion. Recovery time differences were of marginal clinical significance (2 minutes) but more predictable and less variable than other agents.



Weekly Medical News

Alcohol even in ‘safe’ doses linked to hypertension  link

Documented penicillin allergy associated with an increased risk of MRSA and C difficile that was mediated by the increased use of β lactam alternative antibiotics. False penicillin allergy is an epidemic!  link

Hormonal men? nonobese men with migraine exhibited increased levels of the sex hormone estradiol  link

Heat stable Carbetocin (not needing refrigeration) equivalent to Oxytocin in preventing hemorrhage after vaginal birth link

Continuity of care with same doctor is important and even lowers mortality  link

Will Amazon soon sell prescription drugs?  link

Losing nails from fish pedicure! (Or is it just high heels?!)  link

Apixaban for AFib was found to be the safest drug, with reduced risks of major, intracranial, and gastrointestinal bleeding compared with warfarin. Rivaroxaban and low dose apixaban were, however, associated with increased risks of all cause mortality compared with warfarin, unclear reasons  link

Alcohol shrinks your brain!  link

Dozens die from heat wave in Quebec province (they are probably better at recording it as such than other provinces)   link

Drink coffee. It may help you live longer!  link

Purdue suspends their opioid marketing in Canada. Such a caring company…  link

The FDA employs the best physician advisors that Big Pharma can buy   link