Balanced Crystalloids versus Saline in Critically Ill Adults

Hot on the heels of the pediatric study below ( link ) yet another linking of so-called normal saline to worse outcomes

“Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline”. The % differences were not huge

Nejm

An excellent accompanying editorial, while finding the trial informative,  also cautions the use of composite vs. patient-centred outcomes.

Nejm editorial

And in non-critically ill, another perspective – no mortality benefit but still a renal benefit  link

 

 

Frailty and Ambulatory Surgery

Yet another story on frailty as an independent risk factor after relatively small ambulatory procedures.

“Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities”.

Only local with monitored anesthesia care decreased the odds.

link

 

 

Hyperchloremia and Pediatric Septic Shock Mortality

Albeit an observational study, and the link to fluid type administration not proven to be causal, a pediatric study associates hyperchloremia >110mmol/l to increased mortality and complicated courses in septic shock. It joins an increasing adult literature on the potential harmful effects of hyperchloremia on renal function, immune function, coagulation and cardiac contractility. ‘Normal’ saline 0.9% may be a poor choice for resuscitation or Critical Care with the posssible exception of brain injury, and increasingly suggestions occur to use Lactated Ringer’s or to replace Chloride with Acetate.   link

 

Incentive Spirometry

Despite the still very omnipresent blue incentive spirometer especially after abdominal or thoracic surgery, there is just about no evidence that supports it. Structured deep breathing as well as prehabilitation inspiratory muscle strength training, aerobic and resistance training are more important.

The Choosing Wisely item no. 4 provides Cochrane references in this link

 

Cognitive/ Memory Decline after Surgery / Anesthesia

A headline grabbing study in Anaesthesia suggests middle age memory decline after surgery and anesthesia. The effect was small and says anesthesia and surgery. As always it is unclear how much baseline condition was a marker for decline in this observational study but it joins the growing literature in adults and infants/children (link) on the potential link between anesthesia/surgery and the entire spectrum of delirium/post-op cognitive dysfunction/cognitive decline and even dementia.  link

 

ARDS Chest X-Ray Diagnosis

“The ability of clinicians from various backgrounds and years of experience to correctly identify ARDS according to CXRs is extremely poor, bringing the current ARDS definition into question. An educational intervention did not improve this. Better diagnostic tools for ARDS need to be developed, which may include biomarkers, ultrasound or CT imaging”.

Lke ASA physical status, something subjective is prone to variability and/or error.

Dr. Ferguson’s slide illustrates concisely the 2012 Berlin ARDS definition:

Acute Coronary Syndrome in Non-Cardiac Surgery

This study confirms our feeling that demand ischemia is the predominant etiology after noncardiac surgery rather than thrombotic obstruction or plaque rupture. So our focus should be to ensure prompt treatment of low MAP and volume status to maintain coronary perfusion, adequate oxygenation and anemia correction, sufficient analgesia and perhaps B-Blockers. (An interesting finding was a sizeable “stress-induced Takotsubo cardiomyopathy” incidence).  link