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.

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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’!

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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.

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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

Neuromuscular Depth and Surgical Conditions

In an era where deep neuromuscular blockade is out of fashion, along with residual paralysis concerns, this study shows that in patients undergoing elective laparoscopic colorectal surgery, deep neuromuscular blockade was associated with better surgical conditions than moderate blockade, as measured by a reduction in the incidence of intra-abdominal pressure alarms (as well as surgical rating). The moderate group was reversed with Neostigmine and the deep group with Sugammadex 4mg/kg. The availability of Sugammadex certainly makes this a more feasible practice.

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Assessment of functional capacity before major non-cardiac surgery

Functional capacity is frequently subjectively assessed but this prospective cohort study recommends against it in favour of more objective measures. They compared it with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complication. Only DASI scores were associated with predicting the primary outcome of death or myocardial infarction within 30 days.

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Pre-operative Assessment of Older Patients

A review highlights the specific issues in older patients that should prompt shared geriatric assessment. Traditional anesthetic assessment needs to incorporate frailty (eg. Clinical Frailty Score), cognitive impairment and dementia, depression and anxiety, sensory impairment and increased support should be offered. This blog has many links to frailty and its association with outcome and increased morbidity (  Blog link ).

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Ketamine for Chronic Pain

Another consensus statement, akin to the consensus in acute pain ( blog link ).

The statement discusses the varying evidence for different conditions as well as the types of dosing regimes in conditions such as CRPS, spinal cord injury, fibromyalgia, other neuropathic conditions, cancer, headache and low back pain. The overall impression is that enthusiastic use is perhaps ahead of the evidence.

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Hip Arthroscopy and Fascia Iliaca Block

“Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population”.

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Note however that this block is highly recommended for elderly hip fracture blog link