Hydroxyethyl Starch Ban

Experts have vehemently argued over the European ban on HES, most agreeing on the evidence of increased renal failure and mortality. But a sizeable minority see it as unwarranted and draconian, such as this spirited critique of the flaws in the studies showing adverse outcomes. Note that one of the authors declares competing interest (Fresenius-Kabi makers of  Voluven HES)

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IV Lidocaine for Analgesia

Lidocaine bolus and infusion are now frequently employed as an opioid sparing, anti-inflammatory and multimodal analgesia technique in major surgery and may hasten return of bowel function.

The current study shows benefits in the ER for severe pain and are another option in our war on opioids. The current enthusiasm for Lidocaine in fairly generous doses should be tempered by evaluation for cardiac disease or dysrhythmia, and the potential deleterious effects.

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Slow Release Opiods and Acute Pain

ANZCA release a position paper:

Slow-release opioids are not recommended for use in the management of patients with acute pain.
The inappropriate use of slow-release opioids for the treatment of acute pain has been associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths. Immediate release opiods are the choice in acute pain, barring individual cases of prolonged pain and then  only after careful consideration and monitoring.

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Restrictive Fluids in ERAS Harmful?

RELIEF Trial finds an increased risk of acute kidney injury in the most restrictive fluid protocols in abdominal surgery. They advocate “modestly liberal” fluid regimes. This is a surprise and counter to current regimes of Enhanced Recovery after Surgery (ERAS)

The issue is more nuanced depending on oral intake and how oliguria and hemodynamic perturbation is managed but the overall message seems to be that  ultra restrictive regimes need not necessarily dictate practice at the expense of the kidneys

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nejm editorial

 

Predicting Post Surgical Pain

An interesting blog on the need for better prediction tools to individualize surgery and anesthesia. Higher pre-surgical levels of pain catastrophizing and anxiety have been implicated in both acute and chronic post-surgical pain. PROMs (patient reported outcome measures) are increasingly used and need to incorporate these important emotional and psychological elements. Pinpointing them pre-operatively may lead to more focussed care.

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Procalcitonin-guided antibiotic management in critically ill

Prompt antibiotics are crucial in critical care but de-escalation strategy is less clear and variable, but may be guided in sepsis by biomarkers like Procalcitonin. Initiation in a heterogeneous group may involve confounding variables so this review concludes: ”When evaluating all studies of procalcitonin-guided antibiotics management in critically ill patients, no difference in short-term mortality was observed. However, when only examining procalcitonin-guided cessation of antibiotics, lower mortality was detected. Future studies should focus specifically on procalcitonin for the cessation of antibiotics in critically ill patients”. Harm and organ dysfunction may result from unwarranted antibiotic use.

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