Going To Sleep Is Free, But

Think CPAP Mask After Major Abdominal Surgery

• Categories: Medical Articles, Anesthesia practice
• Printer Friendly|#| Trackback

JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:

I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.

I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.

Screening for AAA Recommended for Smokers Aged 65-75

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

The U.S. Preventive Services Task Force (part of AHRQ) now 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.'

Patients should also be made aware that there is an alternative to open AAA repairs known as 'endovascular repair.' NEJM recently published A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms which concluded:

As an aside, wouldn't it be nice to be able to query our electronic medical record for all patients in our primary care practice who meet this criteria? Oh wait. We don't have EMR's (for the most part).

Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369 -- BMJ

• Categories: Medical Articles, Anesthesia practice, Anesthesia Tips
• Printer Friendly|#| Trackback

BMJ: Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369

This works well. I've been using metoclopramide (Reglan) for perioperative migraine for years, ever since learning about it from a Navy ER doc at Balboa. I don't use metoclopramide for post-operative nausea vomiting (prophylactic or treatment), but that's another blog post.

Simple steps nearly eliminate catheter-related blood infections

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

Eliminating catheter-related bloodstream infections in the intensive care unit :

Well, that last point right there explains the whole effect. In my experience, whenever I place a line in an ICU the nurse disappears. Poof. Gone. "Empowering nurses to stop the...procedure" is just a fancy way of saying "forcing them to stay in the room in case you need anything so you don't contaminate yourself by accident."

[Via Science Blog - Science News Stories]

Perioperative Pacemaker Management

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

In the editorial, Rozner points to the American College of Cardiology perioperative guidelines (pdf) on perioperative cardiac management. The guideline contains a section on pacemakers and AICD's. These guidelines nicely summarize why we worry about using elecrocautery in patients with implanted pacemakers or AICD's:

And their recommendations are as follows:

Kudos to the American College of Cardiology for making these guidelines available free of charge. The more I think about this the more sense it makes to require a pacemaker check within, say, six months of elective surgery and call the supporting company for specifics about any given pacemaker

Liberal Fluid Administration to Improves Recovery After Lap Chole

• Categories: Medical Articles, Anesthesia practice
• Printer Friendly|#| Trackback

Liberal Versus Restrictive Fluid Administration to Improve Recovery:

Yawn. This is a 'me too' study, but does provide yet more support to the idea more fluid is good during anesthesia. It's important to note that this is for a 'closed' procedure, not an open one. Insensible loses are minimal with this technique.

Anatomy of a Near Miss

• Categories: Medical errors, Anesthesia practice
• Printer Friendly|#| Trackback

Medical errors are insidious. Many, many errors occur that do not lead to a bad outcome, but they are errors nonetheless. Given a different patient or set of circumstances, those same errors could result in injury, death, or at the very least less than optimal care. The following example serves to reinforce this point.

A thin, elderly woman is admitted the morning of her planned multi-level spinal laminectomy, instrumentation, and fusion. She is healthy, active, and appears younger than her stated age. She meets her anesthesiologist for the first time twenty minutes before the case. Upon review of her records, she appears to be free of cardia or pulmonary disease, but he notes laboratory results on the chart which indicate a macrocytic anemia (blood count of 30--normal is greater than 35 or so). The patient does not recall being told this before. No mention is made of this finding in the surgeon's history and physical examination, or elsewhere in the chart. Someone did think to do serum B12 and folate levels, both of which were found to be normal but no note is present to indicate the differential or planned workup. The finding is discussed with the surgeon and the case proceeds.

Error number one: the abnormal laboratory value should have triggered further evaluation. Some evaluation was attempted, but there was nothing in the chart to indicate by whome, or what their conclusion was. Significant blood loss is likely in this case. Starting with a lower hematocrit means less blood can be lost before a transfusion becomes necessary.

Error number two: the anesthesiologist should have cancelled this case due to a new anemia of unknown etiology. The severity of the anemia is such that a blood transfusion will almost certainly be needed. If time had been taken to evaluate and treat the anemia, the blood count may have risen sufficiently to reduce the likelihood of needing a transfusion. Even if the blood count could not be improved, directed donation or intraopoerative blood salvage techniques could have been used. Why didn't the anesthesiologist cancel the case? No good reasons, just all the usual ones. He was afraid the surgeon would be angry. He kne w the patient had been dealing with severe pain and was holding out just for this surgery.

Intra-operative blood loss was approximately 700 cc. Euvolemia was maintained with Hespan and lactated Ringer's solution. The patient was warm, urine output was good, and both blood pressure and heart rate were stable. Her hemoglobin near the end of the case was now 7, and a unit of blood was ordered from the blood bank. When no blood arrived within 30 minutes, the blood bank was called to inquire if there was a problem. No blood sample from the patient was available in the blood bank to cross-match bank blood against. A sample was immediately drawn into a red-top vial and sent. The case ends, patient is extubated successfully, and transported to the recovery room where her vital signs remain stable and urine output good. The anesthesiologist continues with other scheduled cases after giving report and asking the recovery room nurse to administer one unit of blood when it become available.

After another thirty minutes pass, the blood bank calls the recovery room to inform them that the sample was received in the wrong vial. The blood bank used to require a red-topped vial, but now want a lavender-topped vile (the former contains no anticoagulant, the later does). A phlebotomist is called to draw the new sample and the patient received a blood transfusion fully two hours after the anesthesiologist made the decision to administer blood.

Error numbers three through ten: 'what we have here is a failure to communicate.' There was a failure to communicate:

• that blood had not been drawn pre-operatively as ordered (even though the pre-op checklist indicated it had)
  As an interesting aside, this was the first morning the nurses in the pre-op area were asked to use a computerized nursing record rather than their preferred paper method of charting.
• that the blood bank had no specimen to crossmatch blood against after receiving a call for blood.
• that a change had been made in what kind of specimen was needed for crossmatch.
• you can fill in the remainder.

The only reason this patient did not suffer harm from this incident is that she was physiologically very healthy. Imagine a patient with stable but significant coronary disease. That patient would not have tolerated a hemoglobin of seven so well. Imagine a more significant blood loss. It's better to be lucky than good. It's even better to be both.

My response to this event is to draft a 'Go/No-Go' list. My personal decisions on whether to do a case is heavily influenced by what I know the surgeon reaction will be. I'm not saying that's the right reaction, mind you. It's just my reaction (in wanting to please people as I do). A Go/No-Go list is similar to what NASA uses to decide whether or not to launch a space craft. If any item is 'No-Go' the launch is scrubbed. On my anesthesia Go/No-Go list, if I discover an item in a patient chart that's on my list, launch is scrubbed and the case is rescheduled. New, unexplained anemia is certainly on that list, especially in light of a surgery likely to result in significant blood loss. I need to spend some serious time adding to this list. I'll post it as a work in progress.

One Shot Eases Pain After Surgery

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

It is well known that the injection of a small dose of morphine into the epidural space or cerebral spinal fluid can provide significant post-operative pain relief for as long as 24 hours. The FDA has approved a liposome formulation of morphine that can double that duration. DepoDur, a morphine sulfate extended-release liposome injection, was approved in May, 2004.

More information at SkyePharma.

[Via Yahoo! News: Health]

Yahoo! News - Anesthesiologists Vulnerable to Drug Abuse

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

Yahoo! News - Anesthesiologists Vulnerable to Drug Abuse:

and

Wrong. (I love telling Harvard people that.) I have yet to meet a monitoring system I can't beat if I really want to divert drug.

Anesthesia Can Dim Elderly Patients' Minds (?)

• Categories: Anesthesia practice
• Printer Friendly|#| Trackback

'Anesthesia Can Dim Elderly Patients' Minds' or
Longitudinal Asssessment of Neurocognitive Function in Elderly Patient after Major, Noncardiac Surgery (pick your title):

The actual scientific abstract is here.

Though intriguing, it's only an abstract. There are so many confounding factors, it's really hard to know what to make of this on first blush. Where's the control group? Wouldn't it be better to have a control group that did NOT have surgery or anesthesia at all and see how they fared after two years?

[Via Yahoo! News: Health]