ACP Guideline: Nondrug Treatments Should Be First-Line Therapy for Low Back Pain

Nondrug treatment alternatives should be considered as first-line therapy for patients with low back pain according to an updated clinical practice guideline from the American College of Physicians | Anesthesiology News

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The new guideline offered three main recommendations for treating acute (less than four weeks), subacute (four to 12 weeks) and chronic (>12 weeks) LBP:

  •  Nonpharmacologic treatments such as acupuncture, heat packs and massage are strongly recommended because acute or subacute LBP is expected to improve over time regardless of treatment.
  •  Nonpharmacologic treatment such as exercise, multidisciplinary rehabilitation, yoga and tai chi should be initially used for patient with chronic LBP.
  •  Only after these treatments are deemed ineffective should nonsteroidal anti-inflammatory drugs be considered as first-line therapy.

Read the full article here

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Advantages and disadvantages of reducing local anesthetic requirements in children

Walker, B.J. (2017) Journal of Clinical Anesthesia. 38(5) pp. 158–159

Prior to the widespread use of ultrasound guidance in regional anesthesia, higher volumes of local anesthetic were often required to achieve reliable blockade with landmark and neurostimulation techniques.

The ability to clearly visualize neural structures with ultrasound guidance has resulted in more precise delivery of local anesthetic around the target nerve or plexus, which should theoretically reduce the risk of complications such as local anesthetic systemic toxicity (LAST) as well as tissue toxicity to nerves and surrounding muscle.

Read the abstract here

Pain Assessment in INTensive care (PAINT)

Kemp, H.I. et al. Anaesthesia. Published online: 19 February 2017

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines.

The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician-documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.

Read the full abstract here

Whats New in Obstetric Anesthesia: The 2016 Gerard W. Ostheimer Lecture

Hess, P.E. (2017) Anesthesia & Analgesia. 124(3) pp. 863–871

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This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States.

Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care.

Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care.

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Protocol Lacking for Post-op Delirium

While 70% of anesthesiologists say they “frequently” or “occasionally” encounter postoperative delirium in their practices, more than three-fourths (77%) lack a process to screen for at-risk patients | Anesthesiology News

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A survey of nearly 300 anesthesiologists revealed that postoperative delirium is extraordinarily common worldwide, with 95% of respondents reporting they have had such a patient. However, 60% said they did not commonly discuss possible neurologic complications with their patients prior to surgery. In addition, 84% said their hospital or clinic did not have protocols to prevent postoperative delirium and 73% said their facility lacked protocols to manage delirium when it occurred. Of anesthesiologists without a screening process, 88% said they would consider implementing one.

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Labor or Cesarean for Superobese Women?

Rates of severe maternal and neonatal morbidity were similar among superobese women undergoing primary cesarean delivery versus a trial of labor, most often ending in vaginal delivery | Clinical Anesthesiology

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Researchers say a prospective clinical trial is needed to determine whether one method of birth is superior to the other in mothers who are superobese.

According to Alexander Butwick, MBBS, FRCA, MS, among women who are superobese, rates of cesarean delivery are particularly high (≥50%), but little has been known about how delivery mode affects perinatal and neonatal outcomes. Dr. Butwick, who presented the findings at the 2016 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstract 01-02), is associate professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine, in California.

Over the years, clinicians have observed that obesity is associated with an increased risk for obstetric, perinatal and anesthetic morbidities. Obese pregnant women are at an increased risk for gestational diabetes, preeclampsia, operative delivery, postpartum infection and venous thromboembolism.

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Antibiotic therapy in critically ill patients

Martin-Loeches, I. et al. European Journal of Anaesthesiology. Published online: 30  January 2017

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.

At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.

Read the abstract here