Liposomal Bupivacaine and Opioid Use

Strong marketing of liposomal Bupivacaine (Exparel) has occurred with its supposed long lasting effects. From local infiltration first, it was approved for nerve block based only on placebo comparison rather than existing regimes. This study of its use for total knee arthroplasty finds that liposomal bupivacaine was not associated with a clinically important reduction in inpatient opioid prescription, length of stay, or opioid-related complications in patients who received current multimodal pain management techniques including a peripheral nerve block. Its place in pain management has yet to be fully defined.



Intra-Abdominal Hypertension

A Canadian study to determine the prevalence of intra-abdominal hypertension (IAH) finds a higher than expected rate.

30% at admission, another 15% during admission.

Abdominal Compartment Syndrome 3%

28% in non-ventilated patients.

Higher mortality vs. those without IAH (30% vs. 11%)

Predictors of IAH included obesity, mechanical ventilation and >3L 24 hour fluid balance.

They advocate for possible routine intra-abdominal pressure measurement in ICU, which is simple and inexpensive.


Traumatic Brain Injury and Hypothermia

A systematic review on therapeutic hypothermia finds the same results as known: “High-quality studies show no significant difference in mortality, poor outcomes, or new pneumonia. In addition, this review shows a place for fever control in the management of traumatic brain injury“. 

As in the post cardiac arrest scenario, 36° is just as good without the potential harmful effects of hypothermia, but fever or hyperthermia should be aggressively managed.


Surviving Sepsis Update

Sepsis is now considered an emergency and this update seeks to compress the time frame of the treatment bundle into 1 hour:

Measure Lactate, blood cultures, then antibiotics, IV fluids and vasopressors.

There is some debate among experts as to whether all patients need 30mL/kg fluid with increasing awareness of fluid excess harms.



Sepsis Survival and Acute Organ Dysfunction

A retrospective study finds that acute neurologic dysfunction during sepsis hospitalization most strongly increased the risk of long-term mortality, whereas other types of organ dysfunction had a relatively modest impact on long-term outcomes. It is consistent with the known evidence of the deleterious effects of conditions such as delirium and cognitive dysfunction on mortality.


Neurological insult was also found to be a critical predictor of pediatric critical care outcome in another earlier study Link



APRICOT Study – European Pediatric Anesthesia

A study of severe adverse pediatric anesthesia events across Europe, e.g. respiratory, cardiac, neurological, allergic. Intubation was a marker for increased adverse events, as was emergency surgery, and case volume / pediatric experience of the providers. Children younger than 3 years and those with prematurity, genetic/metabolic/neurological comorbitities, snoring, airway reactivity, with fever or taking medication are at increased risk of severe critical events and should be anesthetized in high-volume pediatric centres.




Lumbar Puncture & Dual Anti-Platelets

While not a study on spinal anesthesia, the Mayo Clinic review on lumbar puncture is relevant. They found no cases of spinal hematoma in 100 cases of LP in the presence of dual anti-platelet therapy. The study is small and retrospective, and the need for diagnostic puncture may possibly (pending further studies) be very important and justify the risk; an overwhelmingly strong absolute indication for spinal anesthesia is not so evident, and this small review is unlikely to change anesthesia cautious practice.