Postoperative Delirium and Long-term Decline in Activities of Daily Living

Delirium occurs all too commonly in the elderly after surgery, in a quarter of elderly patients after major elective and urgent major orthopedic surgery in this study.

The deleterious impact of delirium is well documented by now, although some studies do not prove causation versus association, but the conclusion adds more to this evidence:

“Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.”

The follow up occurred between 24 and 36 months after anesthesia and surgery.

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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Operating Room Humidity

Some ORs experience rises in humidity in summer. This APSF free answer to a query discusses the rationale and impact of working outside the generally recommended humidity levels 20 – 60%.

Low humidity could affect shelf life or generate electrostatic sparks. High humidity is uncomfortable for staff and could increase wound infection or cause mildew or mild in the longer term. The evidence on both fronts is sparse but equipment and supplies often specify ranges that prudent organizations adhere to, which may involve suspending operations.

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Reducing pain in infants, children, and adolescents

This Cochrane Special Collection highlights the evidence for reducing both chronic and acute pain in infants, children, and adolescents.

Some areas are still devoid of good evidence, but this review includes links to a large number of topics. Chronic pain topics include the use of antidepressants, anti-epileptics, NSAIDS, acetaminophen, and opioids in non-cancer pain. A list of reviews of different opioids for cancer pain is included. Various opioids as well as psychological interventions are surveyed in acute pain management.

The list is comprehensive and full text is available at:

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Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock

Numerous studies have advocated combinations of Thiamine, Vitamin C and Steroids in septic shock in adults, but randomized studies have yet to convince majority opinion on outcome improvement.

This Pediatric study used Thiamine and reported improvements in Lactate clearance, but again this is a surrogate outcome measure and does not demonstrate mortality improvement, nor does it prove causation. So it re-emphasizes the need for further randomized controlled studies.

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Vitamin C, Steroids and Thiamine for Sepsis

One might be forgiven for assuming that this is a “revolutionary” and “astounding” treatment for sepsis – the cocktail of steroids, high dose vitamin C and Thiamine propounded almost by a single person, Dr. Paul Marik, based on tiny observational personal studies.

This is an important commentary on the state of wild claims not supported by a single randomized trial in Sepsis.

It is dubbed “science by press release” in this JAMA article. While everyone hopes for a new effective treatment for Sepsis, hype ahead of the evidence is not the way of science.

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Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block

Hemi-diaphragmatic paralysis from Phrenic Nerve Block is a frequent accompaniment to Interscalene Brachial Plexus Block that may be detrimental to those with compromised respiratory function.

This randomized trial compared the more selective targeting of the nerves using the more novel Superior Trunk Block employing ultrasound.

Conclusions: “Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.”

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