The job is not done on discharge from ICU – in this review of sepsis (that likely applies in most part to other critical illnesses) a constellation of issues is reviewed following ICU stay: readmission, anxiety, depression, cognitive, PTSD, neuromuscular and functional impairment, renal dysfunction, infection, heart failure… swallowing assessment and aspiration pneumonitis increasingly are increasingly emphasized.
There is a reasonable chance of surviving to hospital discharge and further in Do Not Intubate patients with comfort measures only status after non-invasive ventilation. Hospital survival was 68% for chronic obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy. Survival was comparable for patients treated in a hospital ward versus an ICU. Pooled survival at hospital discharge was 56% and 32% at 1 year. This data suggests that comfort care can encompass non-invasive ventilation which would be acceptable to many or most such patients
In a specific subclass of pediatric patients – those with risks for adverse respiratory events, Sevoflurane was compared to Propofol for induction. Risk factors included recent cold, history of wheezing or nocturnal cough, passive smoking, allergic history or eczema. There was a higher incidence of adverse events in the inhalational group, such as desaturation, coughing, airway obstruction, laryngospasm, post-op stridor. Bronchospasm was not increased (LMA was the technique). IV induction where possible may be a better option in such patients
Clinical practice recommendations from the ESICM. The basic focus is on crystalloids and avoidance of colloids, albumin or hypotonic dextrose containing fluids. CVP is discouraged as an endpoint, as it is in general currently. Clinical assessment and monitoring of electrolytes and osmolality are recommended
Once again, pre-eclampsia is a red flag for coronary artery diseases development, not just a pregnancy event. link
Nasal influenza vaccine FluMist to return to the market winter 2018 link
FDA doesn’t find Bisphenol A (BPA) a health risk link
People are popping too many NSAIDs without regard for risks link
Potential risk of toxic metal exposure from the coils in e-cigarettes. Regulation vacuum for vaping continues link
ST elevation MIs in-hospital present atypically or silently and face delay in diagnosis and management link
The eyes have it – junior and expert surgeons have different gaze, blinking rate, size and change of pupils size during surgical procedures link
Adding inhaled steroids to LAMA/LABA benefits COPD especially with asthma features. link
(but a modest hip and upper limb fracture risk increase from steroids link
For high-order Cesarean, sutures outperform staples for wound complications. Yet again, stop using staples! link
Sudden cardiac arrest in the young: minority were sports related (but shockable and more survivable with CPR); surprising incidence of modifiable risk factors like smoking, obesity, diabetes, hypertension, dyslipidemia link
Baclofen largely ineffective for alcohol use disorders link
The Lancet calls out Canada on bad indigenous healthcare and overseas aid link
Two thirds of depressed teens do not get treatment Screen all from 12, says AAP link
Maternal and fetal outcomes better (with some cautions) after sleeve gastrectomy link
A study suggests folic acid and multivitamin supplementation before and during pregnancy reduces autism spectrum disorder risk link
1 in 4 teens has received a sext. Non-consensual forwarding is a social and legal issue link
No link between depression and progestin-only birth control link
Trimethoprim for UTI in the elderly linked to renal injury and Hyperkalemia especially in those on renin angiotensin system blockers or potassium sparing diuretics link
Most CIN2 lesions regress in a year or so in young women <35 so active surveillance may be appropriate in selected followup-adherent patients and where midterm loss or preterm birth is a concern link
30% Physicians have burnout – and this is in the Cleveland Clinic! link
Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients link
The rapid and complete reversal of neuromuscular block with Sugammadex is undisputed. Other benefits that might justify its cost have been postulated. The current study did not find any difference in nausea and vomiting compared to Neostigmine/Glycopyrrolate. Diplopia, dry mouth and 2 hour sedation scores were improved but no outcome differences apparent at 24 hours. In the real world, rescue Sugammadex after a misjudged attempt at reversal would seem to save a whole lot of trouble! link
Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A retrospective analysis shows the majority can be done under neuraxial anesthesia with selective conversion to GA. Some variables associated with conversion included high order Cesarean, fibroids, >4 RBC transfusion and high post-op acuity (including ICU admission) but the only independent predictors for GA conversion after adjusting for confounding were surgical duration and >3 Cesareans. link
Smaller centres may not always be as appropriate in view of the need for ICU and/or arterial embolization.
In the eye of the opioid storm, some data on the use of multimodal analgesia techniques in hip and knee replacement : while not a controlled trial, the data encourage our use of techniques such as nerve blocks, acetaminophen, NSAIDS, COX2 Inhibitors, gabapentinoids, and ketamine. Benefits included lower opioid use, reduced respiratory and gastrointestinal side effects, as well as reduced length of stay link ASA
Just when we thought the ADRENAL trial ( link ) put a damper on steroids, Annane brings us another study.
In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo. Hyperglycemia was more common.
Steroids will likely continue to be used in septic shock, even for their effects other than mortality benefit in the ADRENAL trial link