Sunday, October 24, 2004

Review of Pediatric Sedation

Review of Pediatric Sedation:

""Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.""

[Via Anesthesia and Analgesia: Current Table of Contents]

Surgical Cause of Vocal Cord Paralysis

Guilt by proximity? On more than one occasion (including one very recently), I've received calls from patients complaining of laryngeal symptoms after my general anesthetic. In every case, their surgeon suggested to them that since their symptoms are in their voice box, it must have been something the anesthesiologist did since they stuffed a tube in there. Here's a great example of why it 'ain't necessarily so:'

Vocal cord palsy as a complication of adult cardiac surgery: surgical correlations and analysis.

Author(s): Dimarakis I; Protopapas A;

""Vocal cord palsy after adult cardiac surgery is often attributed to non-surgical mechanisms as tracheal intubation and central venous catheterisation.It may also be caused by injury of the recurrent laryngeal nerves by surgical dissection. We hereby present a review of relevant clinical reports. The cumulative incidence was 1.1% (33 in 2980). Main reported surgical mechanisms of injury were harvesting of internal thoracic artery and topical coldcardioprotection. Bilateral nerve palsy has been lethal on at least one occasion. Where vocal cord injury followed harvesting of the left internal thoracic artery, it was reported ipsilateral to the conduit." "

European journal of cardio-thoracic surgery: official journal of the European Association for Cardio; 2004 Oct 1;26(4) p773 - 775

[Via Journals To Go]

Thursday, October 21, 2004

BMJ Review: Risks of general anaesthesia in people with obstructive sleep apnoea

Risks of general anaesthesia in people with obstructive sleep apnoea

""Summary points

Patients with obstructive sleep apnoea are at high risk of developing complications when having surgery or other invasive interventions under general anaesthesia, whether or not the surgery is related to obstructive sleep apnoea

Surgeons of all specialties, and especially anaesthetists, should be aware that undiagnosed obstructive sleep apnoea is common

They should be alert to patients who are at risk of having obstructive sleep apnoea and be aware of the potential preoperative and postoperative complications in such patients

Management options include alternative methods of pain relief, use of nasal continuous airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used

An algorithm for management of difficult airways should be established""

Failing the Public Health — Rofecoxib, Merck, and the FDA

Failing the Public Health — Rofecoxib, Merck, and the FDA

" "I believe that there should be a full Congressional review of this case. The senior executives at Merck and the leadership at the FDA share responsibility for not having taken appropriate action and not recognizing that they are accountable for the public health. Sadly, it is clear to me that Merck's commercial interest in rofecoxib sales exceeded its concern about the drug's potential cardiovascular toxicity. Had the company not valued sales over safety, a suitable trial could have been initiated rapidly at a fraction of the cost of Merck's direct-to-consumer advertising campaign. Despite the best efforts of many investigators to conduct and publish meaningful independent research concerning the cardiovascular toxicity of rofecoxib, only the FDA is given the authority to act. In my view, the FDA's passive position of waiting for data to accrue is not acceptable, given the strong signals that there was a problem and the vast number of patients who were being exposed." "

Emphasis mine.

NEJM: Financing Medicare in the Next Administration

Financing Medicare in the Next Administration (free full text)

" "Because of its size and political impact, Medicare will rank high on the domestic policy agenda of any incoming administration. When that administration assumes office in January 2005, Medicare will account for more than 13 percent of total federal expenditures; the only larger domestic program will be Social Security, which will account for 21 percent.1 By fiscal year 2007, with the phase-in of the prescription-drug benefit, Medicare's share of federal spending will increase to almost 16 percent. In short, the new administration will find the scope of any new initiatives limited by the needs of the Medicare behemoth." "

Wednesday, October 20, 2004

Access to Physicians Figures Prominently In Complaints

Annals of Family Medicine: Patient Reports of Preventable Problems and Harms in Primary Health Care:

" "Conclusion: The errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities." "

[Via Science Blog - Science News Stories]

Monday, October 18, 2004

How Technology Failed In Iraq

MIT Technology Review: How Technology Failed In Iraq

" “Next to the fall of Baghdad,” says Marcone, “that bridge was the most important piece of terrain in the theater, and no one can tell me what’s defending it. Not how many troops, what units, what tanks, anything. There is zero information getting to me. Someone may have known above me, but the information didn’t get to me on the ground.” Marcone’s men were ambushed repeatedly on the approach to the bridge. But the scale of the intelligence deficit was clear after Marcone took the bridge on April 2." "

Saturday, October 16, 2004

Don't Get Admitted On The Weekend

Effects of weekend admission and hospital teaching status on in-hospital mortality.

The American Journal of Medicine.; 2004 Aug 1;117(3) p151 - 157

Conclusion: Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.

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