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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Acute Kidney Injury in ICU and Frailty

Both acute kidney injury in critical care and increased frailty in ICU survivors is frequent. This study shows a link between the occurrence of acute kidney injury and subsequent frailty:

Acute kidney injury in survivors of critical illness predicted worse frailty status 3 and 12 months postdischarge. These findings have important implications on clinical decision making among acute kidney injury survivors and underscore the need to understand the drivers of frailty to improve patient-centered outcomes”.

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Chronic Post-Surgical Pain

A review describes persistent post surgical pain, which is not uncommon after procedures such as amputation, thoracotomy, hernia, Cesarean, cholecystectomy, hysterectomy, mastectomy and hip replacement.

Mechansisms of pain sensitization and hyperalgesia are discussed. Risk factors include pre-operative pain, opioid exposure and psychological factors, nerve damage and importantly the intensity of acute postoperative pain (whether causal or just a marker is unclear).

A thorough review of different modalities is presented: anti-inflammatories, steroids, local anesthetic infusions, nerve blocks and epidurals, wound infiltration and catheters, Ketamine, Dextromethorphan, Nitrous Oxide, Gabapentinoids, Clonidine and Dexmedetomidine.

While the evidence is inconsistent and no critical intervention is identified, all the above are clearly important in multimodal analgesia and limiting opioids and opioid induced hyperalgesia; minimizing acute postoperative pain may prevent sensitization.

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TAP Block for Cesarean

There are now a dizzying array of ultrasound guided abdominal wall blocks, e.g. Erector Spinae, Quadratus Lumborum, Rectus Sheath, Ilioinguinal, Iliohypogastric and more, some overlapping terminologically and their overall place in multimodal analgesia to be fully elucidated.

This study finds benefit post-Cesarean in the I-TAP (ilioinguinal transversus abdominis plane block) group after spinal anesthesia despite intrathecal morphine and non-opioid oral analgesia. Use of PCA Fentanyl was less (a study intervention only, and not their usual practice). They plan further study to determine how clinically significant this is, as other studies have not found it to add much to multimodal analgesia.

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Health News

Varenicline appears to be associated with an increased risk of cardiovascular but not neuropsychiatric events, contrary to recent study  link

A study shows that high intakes of oily fish, fresh legumes and vitamin B6 and zinc are associated with a later onset of natural menopause while a high consumption of refined pasta and rice is associated with an earlier age at natural menopause.  link

Adopting a healthy lifestyle could substantially reduce premature mortality and prolong life expectancy in US adults – nothing new except getting people to eat healthy, keep BMI normal, not smoke and exercise, and keep alcohol low  link

Tick and mosquito borne infections spreading rapidly in the US   link

Compared with saphenous venous grafts, use of radial-artery grafts for CABG resulted in a lower rate of adverse cardiac events and a higher rate of patency at 5 years of follow-up. link

Outrageous scandal and accusations of a coverup in Irish cervical cancer screening botching  link

Child mortality in England twice that of Sweden. Socioeconomic disadvantage contributes to child mortality through its association with adverse birth characteristics  link