Should anesthesiologists have to confirm effective facemask ventilation before administering the muscle relaxant?

There is ongoing controversy as to whether effective facemask ventilation (FMV) should be established following induction of anesthesia before a muscle relaxant is administered. The rationale for such practice is the belief that, should FMV be ineffective, non-paralyzed patients can be woken up, and subsequently an alternative airway management can be considered. However, the chances of successfully restoring adequate spontaneous respiration before severe hypoxemia develops in an anesthetized, apneic patient who is prone to anesthetic-induced respiratory depression and airway collapse are very small. On the other hand, the overall evidence shows that muscle relaxation is likely to improve or leave unchanged, but not to worsen, the quality of FMV. Furthermore, muscle relaxation will facilitate placement of a supraglottic airway device and endotracheal intubation, interventions which may become essential should the patient become hypoxemic during failed FMV. Thus, the earliest administration of a muscle relaxant following induction of anesthesia may well be the most effective and safest practice. Insistence on demonstration of adequate FMV before administration of a muscle relaxant is more of a ritual than an evidence-based practice. It should therefore be abandoned.     

Is it time to reconsider subcutaneous administration of epoetin?

Anemia treatment in nondialysis chronic kidney disease (ND-CKD) and dialysis CKD patients (D-CKD) has been recently scrutinized in the literature and by the lay press. New evidence suggests that patients receiving epoetin and achieving higher hemoglobin have a higher risk of death and cardiovascular complications. Data from the Centers for Medicare & Medicaid Services demonstrate upward spiraling costs of injectables, especially epoetin, in the care of CKD patients. There is considerable literature favoring the use of subcutaneous administration of epoetin compared to intravenous route in hemodialysis patients. Evidence clearly shows that the subcutaneous route achieves the target hemoglobin level at a lower administered dose. Thus, the same clinical effect can be achieved at a lower cost. Despite the economic and evidentiary justifications for subcutaneous administration of epoetin, adoption of this strategy has been limited, especially in the United States. Reasons include: inflexibility by dialysis providers because of reduced profitability, claims that patients oppose the subcutaneous route because of pain at the site of injection, concerns regarding pure red cell aplasia associated with subcutaneous administration, and greater hemoglobin cycling with the subcutaneous route. In this article, the advantages and disadvantages of the subcutaneous route are reviewed.     

Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery?

Objectives: Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation. Methods: During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus^® video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance. Results: A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25–77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2–71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8–40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7–8.9%) cases. Conclusions: After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.     

Is it unnecessary to attach a temporary pacing wire in off-pump coronary artery bypass?

In open heart surgery, the efficacy of temporary pacing to control perioperative cardiac dysrhythmias is well known. However, a temporary pacing wire is not routinely attached during minimally invasive direct coronary artery bypass because of its less invasiveness. In case of off-pump coronary artery bypass (OPCAB) with mediansternotomy, is it also unnecessary? We report 2 patients undergoing OPCAB without postoperative temporary pacing wire who suffered from possibly fatal rhythm disturbances after operation, and needed long hospitalization. After these experiences, we routinely attach a temporary pacing wire during OPCAB with mediansternotomy. We believe, in case of OPCAB, a temporary pacing wire is as effective as in conventional CABG.     

Antibiotics administration before enema reduction of intussusception: is it necessary?

BackgroundSome centers advocate using antibiotics before enema reduction to prevent septic complications. Our objective was to determine whether using antibiotics before reduction provided any improvement in outcomes.MethodsWith institutional review board approval, patients from 2 centers were compared: 1 where antibiotics were administered, and one where they were not. This retrospective cohort study from January 2005 to December 2010 evaluated demographic data, episodes of postreduction fever, hospital stay, and analgesia requirements.ResultsOne hundred eighteen patients were identified: 83 males (70.3%) and 35 females (29.7%). The median age was 24 months (range, 1-180). Fifty-six patients (57.7%) received antibiotics, whereas 41 (42.7%) did not. Twenty-one patients (17.8%) had missing data and were excluded. The incidence of fever postreduction was not statistically different between groups: 12.8% for those who received antibiotics vs 17.9% for those who did not (P = .7367). No adverse antibiotic reactions were reported. Average time to oral feeds was 7.3 vs 10.6 hours (P = .06), and the length of stay was 1.7 vs 1.4 days (P = .07).ConclusionAlthough antibiotics are administered routinely in some centers, they appear of little value. Financial costs and potential adverse reactions must be considered. Further prospective evaluation is being conducted using a larger sample size to confirm these results.     

Is it safe to discharge intussusception patients after successful hydrostatic reduction?

Purpose

The aim of this study was to evaluate whether discharge from the emergency department (ED) after successful hydrostatic reduction (HR) of intussusception is safe.

Methods

We conducted a single institution review of patient records with a diagnosis code of intussusception from 1995 to 2006. Data collected included age, clinical presentation, imaging, surgical interventions, pathology, recurrence, and disposition. Statistical analysis utilized χ² tests, where P ≤ .05 was considered significant.

Results

A total of 309 patients with intussusception were identified. One hundred twenty-three patients (39.8%) required surgical intervention, 138 (44.6%) patients were managed nonoperatively as inpatients, and 48 (15.5%) were treated nonoperatively and discharged from the ED. There were 18 recurrences (5.8%). Recurrence rates did not significantly differ between patients who required operative reduction and those who were managed nonoperatively with HR and either observed as inpatients or discharged from the ED. Seven patients with recurrences required surgical intervention, and 1 of those children had a pathologic lead point, which was nonneoplastic.

Conclusions

Recurrence rates do not differ between children observed as inpatients and those discharged home after successful HR. Missed neoplastic pathologic lead points were not found in the patients who required an operation after a recurrence. Our data suggests that it is safe to discharge patients selectively from the ED after successful HR.     

Is it safe to stop anticoagulants after successful surgery for atrial fibrillation?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: is it safe to stop anticoagulants after successful surgery for atrial fibrillation? Altogether, 177 papers were found using the reported search, of which 14 were selected that represented the best evidence to answer the clinical question. Selection criteria included study relevance, primary outcome, size of study population and length of follow-up. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The weight of evidence, including over 10,000 patient-years of follow-up, supports the discontinuation of warfarin following atrial fibrillation correction procedures as being safe, with an associated annual thromboembolic stroke rate of 0-3.8% off warfarin, in studies where warfarin was stopped at a mean of 3.6 months (range 0-8 months) after the procedure. However, the confidence of this conclusion suffers from a paucity of high-quality randomized controlled trials in the field, with the main body of evidence coming instead from observational non-randomized studies. The stroke rate also varies with the exact procedure performed; pulmonary vein isolation procedures are the most extensively evaluated and carry the lowest stroke rate following warfarin discontinuation (0-0.4% per annum when performed as an isolated procedure). By contrast, left atrial appendage occlusion by insertion of a transcatheter device has an associated annual stroke rate of 0-3.8% off warfarin. Thus, discontinuation of warfarin following such transcatheter procedures cannot be recommended at this time. Concomitant heart surgeries, such as mitral valve repair have been shown to increase the thromboembolic rate both unpredictably and dramatically, and this review thus identifies concomitant mitral valve surgery as a potentially substantial risk factor for late thromboembolic stroke in patients undergoing corrective surgeries for atrial fibrillation. This review finds in favour of warfarin discontinuation in selected patients at three months post-procedure, emphasizing consideration of the patient's individual risk-factor profile as paramount. This recommendation is in line with the 2010 guidelines for the management of atrial fibrillation produced by the European Society of Cardiology.