Respiratory Risk Assessment

An excellent review of the pre-operative  risk factors for pulmonary complications or respiratory failure post-op.

Age, COPD, recent respiratory infection or pre-op symptoms, ASA Class >II, heart failure. Albumin < 3.5g/dl, smoking, alcohol, functional dependence, sepsis, hepatic and renal disease, anemia, recent weight loss >10%, cancer, impaired sensorium, low oxygen saturation, emergency surgery, thoracic/upper abdominal/ major vascular surgery, duration >2 hours.
Controlled asthma and obesity not major risks, OSA uncertain.

Clinics article

Spinal Cord Injury and Neuraxial Block

Vigilance over complacency in this area. Rare but catastrophic potential of spinal and epidural anesthesia. An article and the NAP3 data. Themes include greater risk in elderly, and epidurals and CSE vs spinal. Obstetric and pediatric risk appears lower. Some preventable incidents like wrong route delivery and hypotension

“Assessed ‘pessimistically’ the incidence of permanent injury after CNB was 4.2 per 100 000, and of paraplegia/death was 1.8 per 100 000. ‘Optimistically’ the incidence of permanent injury was 2.0 per 100 000 and of paraplegia/death 0.7 per 100 000. The incidence of complications of epidural and CSE were at least twice those of spinals and caudals.”

Anaesthesia article

NAP3 findings

Cardiac patient for non-cardiac surgery

A review of current guidelines for managing anesthesia for cardiac patients. Still 12 months of dual antiplatelet therapy with any stent after acute coronary syndromes but a little leeway otherwise – 1 month for bare metal stent and 6 months for drug eluting stents, possibly 3 months for more urgent surgery (but with PCI on site).

Longer durations of dual antiplatelet therapy may be appropriate in the non surgical setting based on individual patient cardiac vs bleeding risk.

We know now that just about all Troponin elevations worsen short and longer term outcome,  and in at-risk cardiac patients, many choose to monitor serial Troponins and EKG post-op as peri-operative MIs are often silent.

Anaesthesia review

Anesthesia Care Handover Risk

Not an issue if you’re on your own like me! But bigger centres involve change of anesthesia provider in mid-case and the risk is real even including mortality JAMA Article

The real issue as in so many situations may be inadequate communication. The case for a standard checklist for handover of care is strong, and will increasingly be electronic Anesthesia-Analgesia article

And the same also goes for post operative care units  APSF article

 

Top 2017 Critical Care Trials

If you’ve spent the entire year viewing CNN’s coverage of Trump, here’s a quick catch up of the year in Critical Care.

The main points:

Restrictive blood transfusion still rules. Fresh blood is no better. Antibiotics are time critical in sepsis.

No oxygen for MIs – unless hypoxic. Routine recruitment maneuvers in ARDS not indicated.

Acetylcysteine and bicarbonate for contrast angiography in high renal risk not helpful.

ICU routine admission for over 75 year old not always necessary.

Individual systolic BP targeting with Norepinephrine reduces organ dysfunction.

Angiotensin II may be next therapy for vasodilatory shock.

You’re welcome. Now back to CNN! Or read the summaries and links at thebottomline.org

ICU Intubation

Unfamiliar environments, inadequate equipment and protocol deviation all contribute to a higher risk in airway management outside the OR.  The full range of support devices, like supraglottic  airways, videolaryngoscopy and cricothyrotomy devices must be available as in the OR. And dark X-ray departments are even scarier!

Of interest they note the use of nasal cannula oxygen under your pre-oxygenation mask increased to 15l/min during intubation attempts as shown effective in other recent studies. And the continuing debate on the effectiveness of cricoid pressure, releasing if it impedes the procedure

Guidelines BJA

Excessive Fluids Ups Mortality

Yet another article on the dangers of the past practice of excessive fluids in abdominal surgery to fill the imaginary and dated concept of “third space”. How to tailor this and avoid hypovolemia remains to be optimized but some ideas include pulse (or systolic) pressure variation or inferior vena cava diameter variation with respiration.

Duke study

Maybe colloids are fighting back

Colloid less complications

Colloids and Renal outcome

But however, a more draconian advisory from Europe on “banning” hydroxyethyl starches that may not apply to those not critically ill  EMA statement