Medical News Weekly

EpiPen shortage in Canada continues link

Deadly Ebola virus returns in DRC  link

Mulpleta approved for surgery in liver disease to boost platelets  link

Drinking while breastfeeding can affect child’s cognition  link

Beware “vaginal rejuvenation” procedures!  link

Pathogens now even becoming resistant to alcohol based hand sanitation  link

Kids gluten free foods may be less healthful link

Rifampin for four months may be a better choice than nine months Isoniazid for latent TB in adults  link

– and also in children link

Should LDL cholesterol be lowered even more?  link

Depo-Medrol should not be used in epidurals. link

 

Acute Kidney Injury, Fluids and Norepinephrine

Norepinephrine is being used to help limit excessive fluid administration in keeping with current enhanced recovery protocols. This study shows that while this agent was not harmful, too restrictive an approach to administration of crystalloids was associated with an increased risk for AKI, particularly in older patients, those receiving antihypertensive medication, and those whose surgery was prolonged. Perhaps “modestly liberal” is the best again as in the Relief trial blog link

link

 

 

Lidocaine & Colonoscopy

DIfferent sedation regimes are used for colonoscopy – Midazolam/Fentanyl or Propofol most commonly, or combinations thereof. Some, as in this study, use Propofol and low dose Ketamine combination. However they added Lidocaine 1.5 mg kg−1 then 4 mg kg−1 per hour. This reduced the amount of Propofol required. “Intravenous infusion of lidocaine resulted in a 50% reduction in propofol dose requirements during colonoscopy. Immediate post-colonoscopy pain and fatigue were also improved by lidocaine“. Some find Lidocaine IV helps gagging during gastroduodenoscopy  also, bearing in mind any dose used topically.

link

 

 

Epidural Depo-Medrol

In a word, don’t! Epidural Methylprednisolone (Depo-Medrol) has a very poor safety record. Concern has long existed in particular for particulate steroids embolizing into small arteries and causing serious neurological issues. This serious problem highlighted by the New York Times link

While non-particulate agents like Dexamethasone are considered safer by some, I do not consider the evidence for epidural off-label use in sciatica sufficient for any benefit as concluded in this meta analysis link

The opioid epidemic has unfortunately resulted in many ineffective alternatives.

Frailty and Surgery Outcome

Something immensely important is being missed if frailty isn’t a major preoperative assessment element.

This study aimed to compare the accuracy of the modified Fried Index (mFI) and the Clinical FrailtyScale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery.

“Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher“.

link

 

Canadian Anesthesia Incident Reporting System

In compliance with WHO patient safety recommendations and other international initiatives, the Canadian Anesthesia Incident Reporting System (CAIRS) is now online at cairs.ca

It is an anonymous, confidential site whose input will be analyzed by experts who will in time deliver feedback to CAS members, to whom it is at present limited.

A full description is available here, link

 

Propofol vs. Sevoflurane and Neurocognitive Recovery

Hot on the heels of potential advantages using Propofol TIVA for better outcome in cancer surgery, a study found that in older adults undergoing major cancer surgery, propofol-based general anaesthesia decreased the incidence of delayed neurocognitive recovery at 1 week after surgery when compared with sevoflurane-based general anaesthesia. It also decreased the occurrence of perioperative tachycardia. A small single center study that will need further research in the whole area of anesthetics and outcome.

link

 

Erythropoietin (EPO) in Cardiac Surgery

A retrospective study compares outcomes in cardiac surgery in those who declined transfusion and received EPO  with those who did not receive EPO or transfusion. Allowing for the limitations of retrospective design, they found no difference in mortality, MI, stroke, thromboembolism, kidney injury, extubation time, ICU or hospital length of stay. The results are encouraging for those who decline transfusion such as Jehovah Witnesses but further larger prospective trials are needed. EPO remains off-label for this use.

link

 

Surgeon-Anesthesiology Relationship

Legendary patient safety advocate Jeffrey Cooper provides his observations on the impact of the surgeon-anesthesiology relationship on patient safety.

Anesthesiology : surgeons are ignorant of medical/anesthesia issues, underestimate surgical time and blood loss, fail to consider health conditions and patient desires, fail to inform of the likelihood of surgical success and magnitude of recovery.

Surgeon: anesthesiologists cancel easily, long turnover time, don’t appreciate scheduling, inattentive and poor communication of hemodynamics, just want to finish the day, don’t change anesthesia for surgeons’ needs.

Instead of an adversarial approach, he suggests an advance huddle on the premise that both presume competence, intelligence, knowledge and a patient interest focus on the part of the other. Where there is legitimate disagreement about what option to pursue, the debate would center on what’s right for the patient, not who is right.

link

 

Blood: Choosing Wisely

Some recommendations of relevance to anesthesia and perioperative care on anemia and blood usage:

Delay elective surgery in patients who have correctable anemia

To reduce iatrogenic anemia, don’t order blood tests unless they are clinically indicated.

Don’t transfuse if there is no active bleeding or laboratory evidence of coagulopathy.

To manage surgical bleeding, use early antifibrinolytic drugs like tranexamic acid rather than blood transfusion if possible.

In nonemergent settings, avoid transfusion when other interventions are available. Discuss alternative strategies during the informed consent process.

link