The Westmead Anaesthesia Blog

Prevention of Pain on injection from Propofol

2011-03-17T21:48:00.001+11:00

This meta-analysis assessed various methods to prevent pain on injection from propofol. This totalled 170 studies and 25,000 adult patients. The most effective methods were using the ante-cubital vein (RR 0.14) and injection of lignocaine combined with venous occlusion (RR 0.29). Interestingly the new MCT/LCT formulation were not very effective with a relative risk reduction of only 0.75. The article also scored an editorial. And it's in a general medical journal too.

No improvement in Hospital Safety

2010-11-26T23:51:00.001+11:00

A study reported in the NY Times, and to be published in the NEJM next Thursday (Nov 2), finds no improvement in Hospital safety. The large long-term observational study in ten US hospitals found harm from medical care is still common (18% of patients) and most incidents are preventable. The commonest causes were related to medication and procedures.

Robotic Prostate Surgery: Marketing wins over data?

2010-11-26T23:17:00.004+11:00

Despite no good short term data, or data on cancer control, the acceptance of robotic prostatectomy is continuing. This article in the NY Times gives insight into the problem of the introduction of new surgical techniques before adequate data shows it to be better, same or worse than established techniques. Robotic prostatectomy has a long learning curve, costs more and takes twice as long.

This difficulty of evaluating new technology in patient care is discussed in an editorial in the NEJM from August.

New CPR Guidelines 2010

2010-10-23T14:37:00.000+11:00

The new CPR guidelines have just been published in Circulation and Resuscitation. They are open acces and can be read here

Reviving the lost art of the physical examination

2010-10-16T10:47:00.001+11:00

Teaching medical students how to do a physical exam

The New York Times reports on the remarkable medical education breakthrough of teaching the ancient and mysterious art of the physical examination. Stanford Medical School has employed Dr. Abraham Verghese solely to teach this skill. This is in an era when the first step in a neurosurgical examination is an MRI scan. Importantly, undertaking a physical examination helps develop rapport with your patient and getting to know them as an actual person. This is something the anesthesiologist should embrace.

The last round for codeine?

2010-10-13T10:45:00.000+11:00

Codeine has been an historically popular drug. This has been particularly due to its availability in many over-the-counter combination analgesic drugs such as Panadeine and cold-and-flu remedies. The problem is that codeine is a pro-drug for morphine which depends on the highly variable pharmacokinetics of individual patients. This editorial from the CMJ argues that it is better and safer for patients to avoid codeine and just use a predictable opioid such as morphine or oxycodone.

Maybe too much pain relief is bad?

2010-10-11T21:37:00.001+11:00

NEJM Sept 29. This recent drug trial and editorial show the outcome of too much analgesia when treating osteoarthritis of the knee. The study drug was Tanezumab, a monoclonal antibody that blocks nerve growth factor which then produces pain relief. Unfortunately the drug was too effective, which caused some patients to wear out their knees so badly they needed knee replacements. Consequently the FDA has put a halt on the studies with Tanezumab.

Transfusion and the microcirculation

2010-10-05T21:33:00.000+11:00

This astounding video of a patient's microcirculation shows what happens when a blood transfusion is given. The results are not pretty.

“Would I be surprised if this patient died within the next year?”

2010-09-23T22:06:00.003+10:00

Palliative care is usually taken to mean death from cancer. Yet many of us will die from a slow progressive decline that is not due to cancer. It has been proposed that a positive answer to the question “Would I be surprised if this patient died within the next year?” should prompt a discussion with the patient and family about dying to allow the best use of the time remaining. Read more in this series in the BMJ

US Government gets tough with recalcitrant drug companies

2010-09-23T21:33:00.006+10:00

A Bitter Pill to Swallow

A BMJ special feature reports how the US government is moving beyond large fines to make Big Pharma behave legally and ethically. Despite imposing fines of up to $500 million dollars there has been no effective change in drug companies' unlawful behaviour. It is just seen as a cost of doing business. The next steps include confiscating drug patents to force drugs to become generic, holding executives responsible and investigating doctors who accept financial kickbacks. See the report here

The surgeon's pact with the patient - "Never give up"

2010-09-11T22:08:00.003+10:00

This article in the NY Times delves into why surgeons don't call "enough is enough" when patients suffer postop complications and undergo repeated re-operations and protracted stays in ICU. Research indicates that during the consent process, the surgeon implicitly indicates to the patient he will undertake to do "what ever it takes". However patients don't see the consent having the same implied meaning.

Anesthesia v Orthopedics

2010-09-03T21:13:00.001+10:00

Here we usually talk about research, data and other such topics. But I could not let this very funny video pass without mentioning. Watch for the condition that the orthopod has not seen before. This one is pure genius.

http://www.youtube.com/watch?v=q0S5EN7-RtI

iPad in Medical publishing

2010-05-27T14:57:00.001+10:00

The editor of the BMJ ponders the impact of the global iPad launch tomorrow and how it will affect the future of medical journals. Overall she gives it a positive wrap. As the traditional print media looks at a downturn in circulation figures, the iPad maybe be a good fit for the information needs of doctors.
Update: BMJ Careers gives a good overview of the potential of tablet computers to improve medical care. Read more here.

Futile Surgery

2009-11-07T17:14:00.002+11:00

Ever wondered why so much time and resources are spent on patients who are going to die? A new book by Ken Hillman "Vital Signs: Stories from Intensive Care" examines the problem that most of us, if we die in hospital, will die in intensive care. This happens even if we have irreversible illness. The treatment does not change the outcome, it just delays death by a short time. Meanwhile the patient is exposed to treatment that may be unpleasant and consume scarce health resources. In effect the ICU becomes the defacto palliative care unit. An extract from the book was published in the Sydney Morning Herald, and an interview with Ken was on ABC Radio National here. Both are well worth a look.

Propofol - a controlled drug?

2009-10-29T08:32:00.004+11:00

Oct 29. At last week's ASA meeting in the US it was recommended that propofol become a controlled substance. This follows acknowledgement that is a drug with real abuse potential and risk of death from self-injecting. Reports from US anesthesiology departments show that death amongst staff is a real risk.

see more on the US decision here http://www.medscape.com/viewarticle/711072

The FDA and Acetaminophen (Paracetamol)

2009-07-21T21:22:00.003+10:00

At a meeting on June 30 an FDA advisory panel recommended to
make four changes to Acetaminpohen (paracetamol) use in the USA.
These are based on reducing the risk of hepatic injury (it's the
leading cause of liver failure in the USA).
1. Reducing the maximum daily dose from 4g to a lower dose.
2. Reduce the maximum single dose from 1g to 650mg for OTC use
3. Making the 1g dose prescription only
4. Remove combination products containing paracetamol.

This is likely to cause significant debate, and also concern amongst
the drug companies.

Watch for further developments about this widely used drug

See further info here:
http://www.time.com/time/health/article/0,8599,1908408,00.html?xid=rss-topstories
http://www.fda.gov/AdvisoryCommittees/Calendar/ucm143083.htm

A good review of perioperative use of paracetamol published in Anaesthesia is here

http://www.ncbi.nlm.nih.gov/pubmed/19087009

Rationing Health Care by Peter Singer

2009-07-18T10:13:00.003+10:00

Peter Singer is a noted philosopher and professor of ethics at Princeton. In this article he makes clear an insightful argument why we can not afford everything we want in health care - even if privately insured. There will not be enough money in the Gross Domestic Product of even wealthy nations to pay for it all. It is good to see this discussion in the public arena. This is recommended reading for all doctors and their patients.

Characteristics of Swine Flu patients admitted to ICU

2009-07-11T22:09:00.005+10:00

July 10. The CDC has published a case series of ten patients that required ICU admission due to Swine Flu infection (H1N1). The Flu season has just commenced in the southern hemisphere.

The patient's had characteristics that are unusual and unexpected.

The ages ranged from 21 to 53 years
Seven were previously well - only three had underlying conditions
Nine of the ten patients were obese (BMI>30)
Five had pulmonary emboli. Two others had a hyper-coagulable state.
Nine developed Multiorgan Dysfunction Syndrome
All required advanced forms of ventilation
Two needed ECMO
Six needed renal replacement therapy
Nine needed vasopressor Rx for sepsis
All ten patients had high dose antiviral drug treatment.
Five have recovered to leave ICU, but 3 have died.

The report recommends:

"In communities in which novel influenza A (H1N1) virus is the predominant circulating influenza virus, oseltamivir or zanamivir should be administered as early as possible to hospitalized patients with suspected novel influenza A (H1N1) virus infection, even before diagnostic testing results are available. "

NICE SUGAR not so sweet

2009-03-26T16:13:00.004+11:00

26/3/09 NEJM. The NICE SUGAR study of glucose control in ICU patients shows that very tight normogylcaemia (4.5 to 6 mmmol/l) had a worse outcome than looser control of blood glucose (8 to 10 mmol/l). 90 day mortality was 27.5% versus 24.9% respectively. This is in contrast to previous studies from Belgium that showed a marked improvement in survival with normoglycaemia in critically ill patients. The accompanying editorial backgrounds the whole issue well.

Opioids and QTc prolongation

2009-03-22T21:22:00.004+11:00

It is known that Methadone can cause QTc prolongation on the ECG which can lead to Torsades de Pointes. This is due to blockade of the curiously named 'human ether-a-go-go related gene' channels (hERG). This study published in the British Journal of Clinical Pharmacology in Feburary 2009 showed for the first time that oxycodone causes the same effect in a dose related manner. Morphine and tramadol do not have this problem. This has implications for patients on high doses of oxycodone especially when taken chronically

Prominent Acute Pain Researcher found guilty of fraud

2009-03-10T20:50:00.005+11:00

BMJ 9th March. Dr Scott Reuben from Baystate Medical center in Massachusetts has admitted to fabricating data in 21 of his clinical studies. Some of these studies have been influential especially on use of celecoxib, Pregabalin and multimodal analgesia. One study described the outcome of 1200 patients having multimodal analgesia after knee surgery. Editorials discuss the problems caused by these highly cited studies and their effect on clinical practice. See Anesthesiology and Anesthesia and Analgesia.

Virtual Transoesophageal Echocardiogram

2009-03-06T20:52:00.004+11:00

This website from Toronto General has an excellent 3D model of the heart and allows an interactive view to facilitate understanding of the sonoanatomy of the heart. It would be useful for anyone who is learning how to use transoesphageal echocardiography.

BJA Theme issue on Pain

2008-08-13T15:12:00.002+10:00

The July 2008 issue of the BJA has a good theme issue about pain. It covers the latest in basic sciences as well as clinical topics. Recommended.

BART study published

2008-05-29T14:10:00.003+10:00

The BART study has been published in today's NEJM.

The BART study randomised cardiac surgery patients to receive either aprotinin, tranexaminc acid or aminocaproic acid.

The finding were a modest benefit for aprotinin for reduction in bleeding, but a higher 30 day mortality. This RCT follows on from an earlier Mangano study which found worse outcome from the use of aprotinin to reduce bleeding in cardiac surgery.

POISE study published in The Lancet

2008-05-15T14:49:00.007+10:00

The POISE study, (metoprolol versus placebo in high risk surgical patients) has just been published. The key findings were fewer MIs but more deaths. The publication was fast tracked, and it is on the Lancet website only. Should be in a print issue soon. The responses will be interesting to read, especially from cardiologists. This is the largest ever RCT in perioperative patients.

See also the associated editorial by luminaries Fleischer and Poldermans, who have been supporters of perioperative beta-blocker therapy. They still advise cautious use of beta-blockers for tachycardia in at risk patients.