Sepsis Recovery / Post-ICU Syndrome

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.

jama link

DNR Patients and Non-Invasive Ventilation

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

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Inhalational vs. IV Pediatric Induction

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

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Medical News this week

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

 

Sugammadex vs. Neostigmine

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 in Placenta Previa

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.

Multimodal Analgesia Benefits

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

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Septic Shock and Steroids -Again!

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