Anesthesiology: Adverse Respiratory Events in Children Who Are Obese.
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Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese.
"[O]bese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea."
JAMA: Effectiveness and Efficiency of Root Cause Analysis in Medicine
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Effectiveness and Efficiency of Root Cause Analysis in Medicine
"Not all actions aimed to mitigate risk are equal. Some actions, like redesigning a product or process, are strong and have a high probability of reducing harm. Other actions, like reeducation or writing a policy, the 2 most common recommendations in health care RCA, are weak and have a low probability of reducing risk."
(Via JAMA current issue.)
Anesthesiology: Predictors of Postoperative Acute Renal Failure
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Predictors of Postoperative Acute Renal Failure after Noncardiac Surgery in Patients with Previously Normal Renal Function
"Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function.
Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated.
Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality.
Conclusions: Several preoperative predictors previously reported to be associated with acute renal failure after cardiac surgery were also found to be associated with acute renal failure after noncardiac surgery. The use of vasopressor and diuretics is also associated with acute renal failure."
Dark Chocolate Proven Healthy, Again
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JAMA: Effects of Low Habitual Cocoa Intake on Blood Pressure and Bioactive Nitric Oxide
"Results: From baseline to 18 weeks, dark chocolate intake reduced mean (SD) systolic BP by –2.9 (1.6) mm Hg (P < .001) and diastolic BP by –1.9 (1.0) mm Hg (P < .001) without changes in body weight, plasma levels of lipids, glucose, and 8-isoprostane. Hypertension prevalence declined from 86% to 68%. The BP decrease was accompanied by a sustained increase of S-nitrosoglutathione by 0.23 (0.12) nmol/L (P < .001), and a dark chocolate dose resulted in the appearance of cocoa phenols in plasma. White chocolate intake caused no changes in BP or plasma biomarkers.
Conclusions: Data in this relatively small sample of otherwise healthy individuals with above-optimal BP indicate that inclusion of small amounts of polyphenol-rich dark chocolate as part of a usual diet efficiently reduced BP and improved formation of vasodilative nitric oxide."
With a change of roughly 3 systolic points and 2 diastolic points I'm not going to stop taking my Prinivil just yet.....
Viagra for Bone Cement Impaction Syndrome?
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In sheep, the phosphodiesterase inhibitor sildenafil (Viagra) prevents the catastrophic changes in pulmonary artery pressure that fat embolism can cause:
Sildenafil Prevents Cardiovascular Changes after Bone Marrow Fat Embolization in Sheep.
"Not All Hyperglycemia is the Same"
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One of my almost daily frustrations is the imprecise description of what kind of diabetes patients have. I'm often told, or see written, that a patient has 'insulin dependent diabetes' just because they are taking insulin. Dr. RW points to the second in a series of articles on diabetes in the journal Clinical Diabetes. It's a good review for me that I may use as the basis for a 'refresher' for the nurses...
[Dr. RW]
Do Specialty Hospitals Call 911 to Save Their Patients, or Transport Them?
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The New York Times has an article titled Some Hospitals Call 911 to Save Their Patients which details two cases of patients having surgery at a specialty surgical hospital, experiencing complications, and then being transferred to a medical center (where they ultimately died). The whole article is written, and certainly the title was chosen, to suggest that 911 emergency services were called in order to treat a deteriorating patient as no physicians routinely stay in-house overnight.
Although I am not familiar with the particulars of the two cases mentioned in the New York Times article, it should be known that 911 would be called for any intra-facility transfer and does not necessarily imply they were called to render care in an emergency or that care was unavailable from other professionals already there.
Isn't it interesting, though, that a patient who is has no objection to getting their care from a CRNA, nurse practitioner, physician's assistant, or other 'health care provider' (after all, it's cheaper, right?) suddenly deems it essential to have a doctor there when things start to go south? Of course they do. I would, too!
If you're flying a commercial flight and the landing gear won't deploy, you feel better knowing the pilot is a former military pilot with years of experience in 'heavies.' If your child's safety is threatened by a stranger, you feel better knowing that highly trained and qualified officers are there to protect you. If you're having surgery and things start to go bad, you want an anesthesiologist, a physician, a smart, independent thinker who doesn't get flustered or do whatever the surgeon says to do. You want me. Not someone who is cheaper, less highly trained, less experienced, someone who will do in 99% of cases.
