Post-Partum Hemorrhage Fibrinogen

Fibrinogen is a key early marker of hemorrhage progression.  A plasma fibrinogen concentration <2g/L has 99.3% specificity for prediction of severe PPH. Viscoelastic tests like TEG and ROTEM can also be useful. Misguided use of Fresh Frozen Plasma as a catch all therapy is still prevalent. The options depending on availability are Fibrinogen Concentrate or Cryoprecipitate.  This article discusses these concepts  link

Epinephrine Bolus in Pediatric Hypotension

A retrospective review of the use of bolus epinephrine (up to 1mcg/kg) in the PICU for temporary control of hypotension as may occur during intubation, peri-arrest or shock. While efffective in restoring blood pressure, questions remain as to its myocardial effects in vulnerable patients, and this as well as dosing differences and calculation error concern makes it unlikely to change Anesthesia practice of utilizing Phenylephrine or Ephedrine in such scenarios. (Compare the studies on Norepinephrine bolus during Cesarean – most are not ready for that change yet!).

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General Medical News

Exercise and not Vitamin D prevents falls in community dwelling older adults link

Software artificial intelligence may replace specialist in diagnosing diabetic eye disease  link

Birth defects occur about two or three times more frequently among babies born to women who took certain SSRI medications, like fluoxetine and paroxetine, early in pregnancy.  link

Another nail in the coffin for the myth of low alcohol consumption being good  link

Vaginal progesterone and cerclage are equally effective for preventing preterm birth and improving perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix  link

Women having Essure contraception should be informed of the risks. But no stronger action from the FDA link

Ambulatory blood pressure stronger mortality predictor than in clinic. Masked hypertension linked to highest mortality and white cost hypertension is not benign either  link

In a meta-analysis, the use of SGLT-2 inhibitors or GLP-1 agonists was associated with lower mortality than DPP-4 inhibitors in type 2 diabetes  link

 

Cannabis-based medicines for chronic neuropathic pain

A Cochrane review throws cold water on the evidence to support cannabis based medications for chronic neuropathic pain. “Since relatively few participants achieve a worthwhile response with cannabis-based medicines, decisions to use these medicines may require stopping rules to avoid the unnecessary exposure to harms in the absence of benefit,” concluded the review authors”.

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“The potential benefits of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD oromucosal spray) in chronic neuropathic pain might be outweighed by their potential harms”

Cochrane link

 

Clinic vs Ambulatory Blood Pressure

An important study from general medicine that impacts us in our pre-admission service. Always seeing patients who say their hypertension is only when they come to hospital – white coat hypertension. This, and it’s opposite – masked hypertension (even more) is shown to be associated with mortality and cardiovascular assessment and advice should be so tailored.

“Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension“.

nejm link