Sunday, February 13, 2005

Think CPAP Mask After Major Abdominal Surgery

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:

" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "

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.



Saturday, February 12, 2005

Citation Classics in Anesthetic Journals

I was listening to some friends talk about taking a large set of information and making it more useful to the user when I thought about a project I helped with to try to remedy this with regard to the body of published literature in medicine. PubMed is the National Library of Medicine's big online database of medical articles (no, I didn't help with that). Searching for a term on PubMed usually gets lots of results but doesn't necessarily get you any closer to finding that key reference that people consider the classic or definitive paper in the field.

As a teacher in academic anesthesia, I saw residents (note the past tense) had little hope of finding the 'right' paper to read unless I gave it to them. If I said 'read about airway management' they would no doubt find some things about airway management, but probably not the paper on airway management. Unless of course they were able to search a subset of articles in PubMed defined in advance to be especially relevant to their field of study. That's how we conceived of the idea of 'Key References'--make it easy to assemble a list of references for whatever purpose. To make it easy, we used a unique identifier for each article called the PubMed ID Number (PMID). Seth Dillingham then wrote a plugin for Conversant that could take that PMID and go to the PubMed system and (politely) request information about the reference such as title, authors, citation, and even the abstract.

'Citation classics in anesthetic journals' by Baltussen and Kindler is comprised of 'seminal advances in anesthesia' which give 'a historic perspective on the scientific progress of this specialty'. The advantage of having them available online as a compilation lies in the fact that they 1) are searchable and 2) linked to related articles in PubMed (something which even the online version of the original article even does not do).

See for yourself: Citation Classics in Anesthetic Journals

After looking up all 100 PMID's for these articles I wrote to the journal editors and suggested they require authors to include PMID's for references they cite in each article but (apparently) failed to make a convincing enough case. Sort of like in, oh, 1995 when I suggested to the editors of another journal that they could put their articles online using Highwire Press and was told that they had their hands full putting back issues on CD.



Monday, February 7, 2005

Wired Magazine: Pain Management in Iraq

The Painful Truth: The Iraq war is a new kind of hell, with more survivors - but more maimed, shattered limbs - than ever. A revolution in battlefield medicine is helping them conquer the pain.

" For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain-free despite massive injuries. "

A great story about how military anesthesiologists are making a big difference for our wounded.



Tuesday, January 18, 2005

JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299

JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299 (free article)

Bottom line--it's hard to do it right. I have given chest compressions in the operating room with an arterial line in place so I can see what effect my compressions are having in terms of generating a pressure. Depressing the chest 4 to 5 cm is a lot, but that's the guideline, and that's what it takes to keep blood pumping to the brain. If you're going to the OR and know you're going to have a cardiac arrest, ask for me.



Wednesday, December 29, 2004

NEJM: Ten Years After Gastric Bypass

Too bad it's not free full text, but the NEJM has published a study showing that bariatric surgery results can be good:

" "Two- and 10-year rates of recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia were more favorable in the surgery group than in the control group, whereas recovery from hypercholesterolemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia than the control group; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable." "

Here's a nice graph of the weight loss over the course of the ten year follow up:

The same issue contained another article on obesity in women as it relates to increased risk of death:

" "We estimate that excess weight (defined as a body-mass index of 25 or higher) and physical inactivity (less than 3.5 hours of exercise per week) together could account for 31 percent of all premature deaths, 59 percent of deaths from cardiovascular disease, and 21 percent of deaths from cancer among nonsmoking women." "


[Click for larger image]

It would be interesting to know if weight loss from bariatric surgery confers the same benefit.

Lessons learned from troubles with COX-2 inhibitors - JAMA

JAMA: Arthritis Medicines and Cardiovascular Events—"House of Coxibs" (free full text)

" "In the wake of the high density of new data on coxibs, several important issues now need to be confronted. First, is there any continuing role for coxibs? Only rofecoxib has been shown to reduce gastrointestinal complications compared with naproxen, but valdecoxib and celecoxib have never been definitively confirmed to protect against gastrointestinal complications. While coxib superiority over NSAIDs for relief of arthritic pain has not been shown, many individual patients report pain relief with a coxib but not an NSAID. With the considerably higher cost, marginal efficacy, and known cardiovascular risks of the remaining agents on the market, valdecoxib and celecoxib, it would seem prudent, at the least, to avoid using these agents as first-line therapy. A contraindication is appropriate for patients with established coronary or cerebrovascular disease." "

and the final sentence

" "The combination of mass promotion of a medicine with an unknown and suspect safety profile cannot be tolerated in the future. An aggressive position going forward is necessary not only for ensuring the safety of prescription medicines but also to restore a solid foundation of public trust." "

[Via UK Medical News Today]



Sunday, December 26, 2004

Charite Artificial Intervertebral Discs--ready for prime time?

DePuy Spine/J&J are marketing Charite artificial discs as an alternative to spinal fusion. A recent New York Times report, though pointing out that long term evidence is lacking, was basically positive and contained the following quote from a company representative:

" "Some of the anecdotal evidence for the Charité is impressive." "

Some of the anecdotal evidence? What? This device has been in use in Europe for two decades and that's the best they can do? The Charite web site with information for physicians has results but no references. None.

The one study I did find via PubMed concluded:

" "In this prospective randomized study, both surgical groups improved significantly. Complications of total disc replacement were similar to those encountered with anterior lumbar interbody fusion. Total disc replacement appears to be a viable alternative to fusion for the treatment of single-level symptomatic disc degeneration unresponsive to nonoperative management." "

It may be a 'viable alternative', but there's no data on long term results. Here's what I bet will happen. The FDA will approve the device and ask for long term followup, which is actually done by a company in fewer than half the cases where it is requested by the FDA. (I don't know J&J's record specifically, though.) Patients will read about it and find a surgeon that does the Charite procedure (even if it means going to someone who is not their normal orthopedic surgeon)...and resort to the legal system if their expectations are not met or their long term results are disappointing.

[Via Medgadget]



Tuesday, December 21, 2004

JCAHO Sentinel Event Alert: Patient controlled analgesia by proxy

Sentinel Event Alert Issue 33: Patient controlled analgesia by proxy

" "Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced. However, serious adverse events can result when family members, caregivers or clinicians who are not authorized become involved in administering the analgesia for the patient "by proxy." " "

I had this happen during my training. Healthy patient, uncomplicated anesthetic, uneventful recovery. Three hours after arriving on the floor she had a respiratory arrest. Despite numerous attempts from every quarter to blame my anesthetic (I had used Sufenta, a new synthetic narcotic at that time), it turned out to be the family pressing the PCA button.



Monday, December 20, 2004

I'll have some wine, fish, dark chocolate, fruits and vegetables, almonds, and garlic, please

The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75% -- Franco et al. 329 (7480): 1447 -- BMJ:

" "What is already known on this topic

  • Prevention of cardiovascular disease is limited by high costs and low compliance
  • The concept of a combination pill (the Polypill) to reduce cardiovascular disease by more than 80% was introduced in 2003
  • Pharmacological interventions are not the only option for preventing heart disease; a healthy diet and an active lifestyle reduce cardiovascular disease as well
What this study adds
  • A combined meal of seven food components (the Polymeal) could reduce cardiovascular disease by more than 75%
  • Chocolate, wine, fish, nuts, garlic, fruit, and vegetables are all known to have a positive effect on cardiovascular disease, and have been enjoyed by humankind for centuries
  • Finding happiness in a frugal, active lifestyle can spare us a future of pills and hypochondria"
"



Thursday, December 16, 2004

BMJ: Magnetic bracelets may relieve hip and knee pain

" "Wearing a magnetic bracelet could reduce the pain arising from osteoarthritis of the hip and knee. After randomising 194 people aged 45-80 to wearing a standard strength static bipolar magnetic bracelet, a weak magnetic bracelet, or a non-magnetic (dummy) bracelet for 12 weeks, Harlow and colleagues found that mean pain scores were reduced significantly more in those in the standard magnet group than in the dummy group. Although a few participants allocated to the dummy group did notice the lack of magnetic force, further analysis showed that unblinding did not affect the results." "

The result table is here.

Very interesting results. Can one ever really be blinded as to whether a bracelet is magnetic or not? Wouldn't it just be too easy to 'check' to see if you're in the placebo group or not?



Wednesday, December 15, 2004

Guidelines: Coronary Artery Bypass Grafting

Guidelines updated for Coronary Artery Bypass Grafting (CABG):

" "Key Points

  1. Off-pump CABG, which avoids aortic cannulation and cardiopulmonary bypass, is now available in many hospitals. However, three randomized trials comparing neurologic outcomes after off-pump and on-pump CABG provide insufficient evidence to warrant the conclusion that the off-pump procedure is better for limiting neurologic complications.
  2. The authors note that long-term data from trials of angioplasty versus CABG (most notably the BARI trial) continue to show significant advantages with CABG for preventing death and repeat revascularization in diabetes patients.
  3. Since 1999, both stent use and left internal mammary-artery grafting have become more common. The most recent randomized trial data show that rates of death, MI, and stroke remain similar for CABG recipients compared with stent recipients. The authors also mention that CABG's advantage over stenting for preventing repeat revascularization has narrowed, but remains significant.
  4. In a class I recommendation, the authors write that aspirin is "the drug of choice" for prophylaxis against early saphenous-vein graft closure and should be continued indefinitely.
  5. There is a new class I recommendation for statin therapy in all CABG patients, unless contraindicated.
  6. Hormone replacement therapy should no longer be initiated in women after CABG.
  7. The new guidelines emphasize the importance of understanding how newer antithrombotic and antiplatelet therapies affect bleeding risk in acute coronary syndrome patients who undergo CABG. For example, the authors have made a class I recommendation that clopidogrel be withheld for 5 days before CABG, if clinical circumstances permit.
  8. Several new sections have been added, including those about off-pump techniques, robotic coronary bypass, and the value of clinical guidelines and pathways for guiding postoperative care and improving outcomes." "

[Via Medscape Headlines]

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