Anesthesiology
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WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. ⋯ In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.
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Observational Study
Early Resumption of β Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular Surgery: A Cohort Analysis.
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Beta (β) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume β blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of β blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. ⋯ Resuming β blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.
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Randomized Controlled Trial Comparative Study
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.
Accurately identifying the cricothyroid membrane is foundational for front-of-neck rescue of airway misadventure. Yet the very patients who are at risk of a cannot intubate, cannot oxygenate scenario (eg. obese, neck pathology) are also likely to make identifying the cricothyroid membrane (CTM) difficult.
Naveed and co. compared the accuracy of CTM palpation to ultrasound in a single-blinded randomized trial of 223 patients, with poorly defined landmarks, undergoing CT neck.
The ultrasound group showed a 10-time greater success in identifying the CTM (correct within 5 mm of actual; 81% vs 8%), along with a 5-times smaller mean distance from actual to estimated, than did the palpation group.
So what's the take home?
Given the wide-availability of ultrasound and it's acceptability to patients, any pre-induction marking of the CTM in an anticipated difficult airway should employ neck ultrasound in all but the most obviously-palpable necks.
In an emergent CICO situation, neck ultrasound likely has utility, though at the potential cost of procedural complexity and delay.
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