1. VALUE OF PLATELET TRANSFUSION BEFORE LUMBAR PUNCTURES OR EPIDURAL ANESTHESIA
Estcourt LJ, Malouf R, Hopewell S, et al. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev. 2018;4:CD011980.
Thrombocytopenia is often corrected with platelet transfusions before lumbar punctures or epidural anesthesia. In a Cochrane Systematic Review, Estcourt et al conducted a search for randomized controlled trials (RCTs), non-RCTs (nRCTs), controlled before–after studies, interrupted time series studies, and cohort studies involving transfusions of platelet concentrates given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter. They identified no completed or ongoing RCTs, nRCTs, controlled before–after studies, or interrupted time series studies. No studies included patients undergoing a procedure with epidural anesthesia. No studies compared different platelet count thresholds before a procedure. The authors identified 3 retrospective cohort studies with participants who did and did not receive platelet transfusions before lumbar puncture procedures. There was no observed difference in the risk of minor bleeding (“traumatic tap”) in participants who either received or did not receive platelet transfusions before a lumbar puncture. They found no studies that evaluated length of hospital stay or mortality related to the proportion of patients who received platelet transfusions for lumbar punctures. They found no evidence from RCTs or nRCTs on which to base an assessment of the correct platelet transfusion threshold before performing a lumbar puncture or epidural anesthetic, and found no ongoing RCTs assessing the effects of different platelet transfusion thresholds before lumbar puncture or epidural anesthesia in patients with thrombocytopenia. They concluded that any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants. Thus, the use of a central data collection registry or routinely collected electronic records (“big data”) is likely to be the only method to systematically gather data relevant to this population.
2. DEMENTIA INCREASES RISK OF 30-DAY READMISSION
Sakata N, Okumura Y, Fushimi K, et al. Dementia and risk of 30-day readmission in older adults after discharge from acute care hospitals. J Am Geriatr Soc. 2018;66:871–878.
In this retrospective review of a national database of >1.8 million patients ≥65 years of age discharged from acute care hospitals, Sakato et al assessed the association between those with dementia and the incidence of unplanned hospital readmission within 30 days. Overall, 15% of patients had dementia, but the prevalence was >50% in patients with hip fractures and aspiration pneumonia. These latter patients were older, were more likely women, had more comorbidities, were more likely to have long hospital stays, and were more likely to be discharged to nursing homes. Patients with dementia had a higher risk of hospital readmission versus those who did not have dementia (8% vs 4%; adjusted relative risk [aRR], 1.46). But this risk varied with their primary diagnoses at the time of initial hospitalization (aRR with hip fracture, 1.5; aRR with cholecystitis, 1.00).
3. VIDEO LARYNGOSCOPY AND ADVERSE EVENTS IN NEONATAL TRACHEAL INTUBATION
Pouppirt NR, Nassar R, Napolitano N, et al. Association between video laryngoscopy and adverse tracheal intubation-associated event in the neonatal intensive care unit. J Peds. 2018 [Epub ahead of print]. Doi: 10.1016/j.jpeds.2018.05.046.
The safe and effective intubation of neonates remains challenging for neonatologists and anesthesiologists. There is very limited information available concerning the effect of video laryngoscopy on the rate of adverse events during intubation in this population. In this retrospective cohort study, Pouppirt et al assessed the initial intubation courses in 805 intubation encounters in a level IV neonatal intensive care unit by neonatology personnel over a 3-year period. After adjustment for patient and practice characteristics, use of video laryngoscopy with the C-MAC (Karl Storz, Tuttlingen, Germany) was significantly associated with a reduction in tracheal intubation adverse events. These included main-stem bronchial intubation, esophageal intubation with immediate recognition, dysrhythmia, or lip trauma. There was no reduction in severe tracheal intubation adverse events, such as cardiac arrest, pneumothorax, or laryngospasm, or severe oxygen desaturation events. First-attempt success was higher in the video laryngoscopy group although the overall success rate between the 2 techniques did not differ. The authors suggest that video laryngoscopy is a helpful tool in optimizing safety and success of intubation in the neonatal intensive care unit setting.
4. ORO-HELICAL LENGTH AND PREDICTION OF ENDOTRACHEAL TUBE DEPTH IN NEONATES
Lee D, Mele PC, Hou W, et al. The oro-helical length accurately predicts endotracheal tube depth in neonates. J Peds. 2018;200:265–269;e2.
Accurate prediction of ideal oral endotracheal tube (ETT) depth in neonates, especially very low–birth weight infants, is difficult, and several methods have been proposed. ETT malposition can lead to barotrauma, ineffective ventilation, and atelectasis with oxyhemoglobin desaturation. After intubation of 75 neonates at the discretion of the primary team and according to guidelines of the Neonatal Resuscitation Program, chest radiographs were obtained, and the inserted ETT depths were adjusted to the ideal depth between the upper border of the first thoracic vertebra and the lower border of the second thoracic vertebra. Using the postintubation chest radiograph, 3 calculated insertion depths were compared with the ideal depth. These included the “7-8-9 rule” depth (which adds 6 cm to the kilogram weight of the infant) and both the right and left oro-helical length (OHL) depths. The OHL length is the distance from the angle of the mouth to the ipsilateral helix tubercle of the ear. The authors concluded that OHL depth is a reliable and better predictor of ideal ETT depth than the 7-8-9 rule, which tends to overestimate ETT depth in infants with birth weight <1500 g.
5. PSYCHIATRIC DIAGNOSES AND WEIGHT LOSS IN ADOLESCENTS WHO UNDERGO BARIATRIC SURGERY
Mackey ER, Wang J, Harrington C, et al. Psychiatric diagnoses and weight loss among adolescents receiving sleeve gastrectomy. Pediatrics. 2018;142:e20173432.
Adolescents with severe obesity have a higher rate of psychiatric diagnoses. Little is known regarding any association between the nature of preexisting psychiatric diagnoses and weight loss outcomes after bariatric surgery. In this single-institution study, the presence and number of psychiatric diagnoses in 222 adolescents who were evaluated before possible surgery were compared between those who did (N = 169) and did not (N = 53) receive sleeve gastrectomy. The association between preoperative psychiatric diagnoses and postoperative weight loss at 3 and 12 months after surgery was assessed. Seventy-one percent of the adolescents were diagnosed with ≥1 psychiatric disorder, but there were no differences in the rates of different disorders or number of disorders between those patients who did or did not undergo surgery. There was no association between the presence or number of diagnoses and weight loss after surgery. The authors conclude that preexisting psychiatric diagnoses should be identified to provide them appropriate treatment, but should not be considered a contraindication to surgery.
6. PREPROCEDURAL FASTING LESS CRITICAL FOR SEDATION OF CHILDREN UNDERGOING PROCEDURES IN THE EMERGENCY DEPARTMENT
Bhatt M, Johnson DW, Taljaard M, et al. Association of preprocedural fasting with outcomes of emergency department sedation in children. JAMA Pediatr. 2018;172:678–685.
These authors examined the impact of fasting duration before procedural sedation in the emergency departments of 6 Canadian hospitals among 6183 children <18 years of age (median, 8.0 years; interquartile range, 4–12 years), nearly 100% American Society of Anesthesiologists (ASA) physical status I or II; 66% for orthopedic reductions, and 62% utilizing only ketamine. Only 5% received liquids sooner than ASA fasting guidelines of ≥2 hours, while 2% received solids within 2 hours, 14% within 2–4 hours, and 33% within 4–6 hours (all below ASA fasting guidelines). No episodes of clinically apparent pulmonary aspiration were observed; 11.6% experienced any adverse events (5.5% oxygen desaturation), and 1% experienced a serious adverse event. Vomiting occurred in 5.1%, but occurred during sedation in only 0.1%. The incidence of any of these adverse events was not associated with duration of fasting and not higher in those who met or did not meet ASA fasting guidelines. While contentious, delaying sedation to meet these guidelines may not be warranted in healthy pediatric patients for these short procedures not requiring airway manipulation in the emergency department. The 11.6% adverse event rate is notable, although apparently not associated with fasting interval.
7. HIGH VERSUS LOW ARTERIAL PRESSURE DURING CARDIOPULMONARY BYPASS
Vedel AG, Holmgaard F, Rasmussen LS, et al. High-target versus low-target blood pressure management during cardiopulmonary bypass to prevent cerebral injury in cardiac surgery patients: a randomized controlled trial. Circulation. 2018;137:1770–1780.
Lack of clarity remains regarding the proper mean arterial pressure (MAP) target during cardiopulmonary bypass. In this single-center randomized controlled trial of 197 adult patients (average age, ≈67 years; 88% men) undergoing cardiac surgery (55% isolated coronary artery bypass grafting, 42% left-sided valve surgery), Vedel et al compared patients managed with low MAP (40–50 mm Hg; mean, ≈45 ± 7) versus high MAP (70–80; mean, ≈67 ± 5), the latter using phenylephrine or norepinephrine during normothermic cardiopulmonary bypass with a nonpulsatile flow of 2.4 L/min/m2. New evidence of cerebral injury on diffusion-weighted imaging was observed in ≈54% of patients and not different in the 2 groups (52.8% in low MAP group and 55.7% in high MAP group). The volume of these new lesions (primary outcome) was also similar (25 vs 29 mm3). The incidences of clinical evidence of strokes at 30 days (1.1 vs 7.0), new postoperative cognitive decline at 7 days (23% vs 35%), and postoperative cognitive decline at 92 days (9% vs 7%) were also not statistically significantly different in the 2 groups. Thus, vasopressor facilitated high-targeted MAP did not appear to be beneficial. The informative and insightful content of the accompanying editorial is highly recommended.
8. IMPACT OF INTRAOPERATIVE FLUID DOSE ON OUTCOME
Shin CH, Long DR, McLean D, et al. Effects of intraoperative fluid management on postoperative outcomes: a hospital registry study. Ann Surg. 2018;267:1084–1092.
Based on a retrospective analysis of 92,094 adult patients undergoing general endotracheal anesthesia for noncardiac surgery, Shin et al evaluated the association of intraoperative volume of crystalloid and colloid administered with 30-day mortality (primary outcome), respiratory complications, or acute kidney injury. Patients were divided into 5 quintiles of fluid administration from “restrictive” to “liberal” (<900, 900–1100, 1100–1750, 1750–2700, and >2700 mL). Mortality was statistically higher in the lowest (restrictive) and highest (liberal) fluid quintiles (hazard ratio, 1.4 and 1.65, respectively) and least (hazard ratio, 1.0) in the second quintile. The incidence of respiratory complications was statistically significantly higher (odds ratio [OR], 1.3) only in the highest (liberal) fluid quintile, while the incidence of postoperative acute kidney injury was statistically significantly higher in the lowest (restrictive) (OR, 1.7) and highest (liberal) (OR, 1.3) fluid quintiles and lowest in the fourth quartile (“moderately liberal”). Their data indicate that extreme fluid administration (administration of <900 mL or >2700 mL) intraoperatively was associated with adverse outcomes.
9. RESTRICTIVE VERSUS LIBERAL TRANSFUSION STRATEGIES IN OLDER PATIENT WITH HIP FRACTURES
Zerah L, Dourthe L, Cohen-Bittan J, et al. Retrospective evaluation of a restrictive transfusion strategy in older adults with hip fracture. J Am Geriatr Soc. 2018;66:1151–1157.
This single-center retrospective observational study of patients ≥70 years of age with hip fractures compared the outcome of 474 patients after implementation of a restrictive transfusion strategy (hemoglobin, ≥8 g/dL) (in 2012–2016) versus a liberal strategy (hemoglobin, ≥10 g/dL) earlier (2009–2011) in 193 patients. The change to restrictive strategy was associated with less perioperative transfusion (22 vs 33%; P < .01), reduction in red blood cell units per patient (1 vs 2; P < .001), and fewer acute cardiovascular complications (odds ratio, 0.45; P < .002) (acute coronary syndromes 8% vs 17%; acute heart failure, 10% vs 19%), but an increase in rate of transfusion in the rehabilitation setting (18% vs 9%; P < .01). There was no difference in length of hospital stay, time to sitting or walking, in-hospital mortality, or 6-month mortality between the 2 transfusion strategies.
10. PREVENTION OF POSTOPERATIVE ATRIAL FIBRILLATION AFTER NONCARDIAC SURGERY
Oesterle A, Weber B, Tung R, Choudhry NK, Singh JP, Upadhyay GA. Preventing postoperative atrial fibrillation after noncardiac surgery: ameta-analysis. Am J Med. 2018;131:795–804.
In this systematic review and meta-analysis of 21 randomized controlled trials of patients undergoing vascular (3465 patients), thoracic (2757), general (2292), orthopedic (1756), or other (1338) surgeries, Oesterle et al examined the effectiveness of various prophylactic pharmacological agents. β-Blockers (relative risk [RR], 0.32), amiodarone (RR, 0.42), and statins (RR, 0.43) reduced risk, but the incidence of adverse events was higher with use of β-blockers (RR of mortality, 1.33; RR of bradycardia, 2.7) than with the other agents. Calcium channel blockers (RR, 0.55), digoxin (RR, 1.6), and magnesium (RR, 0.73) did not significantly affect the incidence of atrial fibrillation.
OTHER ARTICLES OF POSSIBLE INTEREST
1. Addressing Parent and Patient Mobile Device Use as a Teachable Moment
Erkoboni D, Radesky J. J Peds. 2018;198:5–6.
2. Cognitive Development and Quality of Life Associated With BPD in 10-Year-Old Former Prematures
Sriram S, Schreiber MD, Msall ME, et al. Pediatrics. 2018;141:36.
3. Ten Years of the Surgical Safety Checklist
Weiser TG, Haynes AB. Br J Surg. 2018;105:927–929.
4. Sepsis and Septic Shock. (A Review)
Cecconi M, Evans L, Levy M, Rhodes A. Lancet. 2018;392:75–87.
5. Acute Rheumatic Fever. (A Review)
Karthikeyan G, Guilherme L. Lancet. 2018;392:161–174.
6. Coronary Artery Disease in Patients ≥80 Years of Age. (A Review)
Madhavan MV, Gersh BJ, Alexander KP, Granger CB, Stone GW. J Am Coll Cardiol. 2018;71:2015–2040.
7. Diagnostic Accuracy of Chest Radiograph Versus Lung Ultrasound, in Critically Ill Patients With Respiratory Symptoms
Winkler MH, Touw HR, van de Ven PM, et al. Crit Care Med. 2018;46:e707–e714.
8. Cerebrovascular Events After Cardiovascular Procedures
Devgun JK, Gul S, Mohananey D, et al. J Am Coll Cardiol. 2018;71:1910–1920.
9. What Faces Reveal: A Novel Method to Identify Patients at Risk of Deterioration Using Facial Expressions
Madrigal-Garcia MI, Rodrigues M, Shenfield A, Singer M, Moreno-Cuesta J. Crit Care Med. 2018; 46:1057–1062.
Name: Eugene A. Hessel II, MD.
Contribution: This author helped write the manuscript.
Name: Timothy W. Martin, MD, MBA, FAAP.
Contribution: This author helped write the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.