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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ACUTE AND CHRONIC PAIN
Gabapentinoids not effective for chronic low back pain (September 2017)
A meta-analysis evaluating gabapentinoids (gabapentin or pregabalin) for the treatment of chronic low back pain included eight randomized trials, which were evaluated as three groups . Gabapentin, compared with placebo, resulted in a minimal and nonsignificant improvement in pain, and gabapentin increased the risk of side effects (primarily dizziness, fatigue, mentation difficulties). Pregabalin as primary therapy was less effective than other analgesics. In the largest study of pregabalin as adjuvant therapy, no additive benefit was found, although the adjuvant studies were too heterogeneous to pool. We suggest not treating patients for chronic low back pain with gabapentinoids. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Antiepileptic medications'.)
Opana ER withdrawn from the US market (July 2017)
A long-acting abuse-deterrent formulation of oxymorphone, Opana ER, is being voluntarily withdrawn from the United States (US) market at the request of the US Food and Drug Administration due to concerns related to injection abuse, including reports of thrombotic microangiopathy (TMA) when the oral formulation is injected intravenously (IV) [2-4]. The TMA is thought to be due to an inert component that was added to the formulation to make it crush-resistant and thus deter IV injection. Generic extended-release oxymorphone products remain on the US market. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Oxycodone, hydrocodone, hydromorphone, and oxymorphone' and "Drug-induced thrombotic microangiopathy", section on 'Drugs of abuse'.)
ANESTHESIA FOR PATIENTS WITH COMORBIDITIES
Intraoperative blood pressure management in patients at increased risk for postoperative complications (September 2017)
Whether intraoperative management of systolic blood pressure (SBP) should be based on individualized targets or standard care was evaluated in a randomized trial conducted in nearly 300 patients undergoing major abdominal surgery who were at risk for postoperative complications due to hypertension or other risk factors . In the intervention group, SBP was maintained within 10 percent of the patient’s resting baseline value, with norepinephrine infusion as needed, while the control group received standard care (treatment to maintain the SBP ≥80 mmHg or to prevent a 40 percent or greater decrease from baseline SBP). The primary composite outcome (systemic inflammatory response syndrome with renal, respiratory, cardiovascular, or neurologic dysfunction) occurred less frequently in the intervention group. This study supports individualizing intraoperative management to maintain the blood pressure close to the patient’s baseline in patients at high risk of postoperative complications due to chronic hypertension, age, or other factors. (See "Anesthesia for adult patients with hypertension", section on 'Determination of target blood pressure values'.)
CARDIOVASCULAR AND THORACIC ANESTHESIA
Red blood cell transfusion threshold in patients undergoing cardiac surgery (November 2017)
While the optimal red blood cell transfusion threshold for patients undergoing cardiac surgery with cardiopulmonary bypass is not known, experts have generally recommended transfusion for hemoglobin values less than 8 g/dL. In the TRICS III trial, over 5000 adults at high risk of death were randomly assigned to a restrictive red cell transfusion threshold (transfuse if hemoglobin <7.5 g/dL) or a liberal threshold (transfuse if hemoglobin <9.5 g/dL) . There was no difference in the rate of the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis while, as expected, the rate of transfusion was higher in the group with the higher transfusion threshold. This trial confirms findings in smaller randomized trials and supports our practice to transfuse to maintain the hemoglobin level above 8 g/dL, recognizing that individual patient factors may alter this threshold. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Blood transfusion'.)
Sevoflurane- versus propofol-based anesthesia for lung resection (October 2017)
During open pulmonary resection with one lung ventilation, anesthesia may be maintained with an inhalation technique employing a potent volatile agent or with a total intravenous anesthetic (TIVA) technique. A randomized trial in nearly 200 patients undergoing lung resection surgery demonstrated a lower incidence of mortality in the first year when a sevoflurane-based anesthetic technique was used compared with a propofol-based TIVA technique (2.3 versus 12.5 percent) . Fewer postoperative pulmonary complications (14 versus 28 percent) and reduced expression of lung and systemic pro-inflammatory cytokines were noted in the sevoflurane group. We suggest sevoflurane as the primary agent to maintain anesthesia during open pulmonary resection with one lung ventilation, with administration of supplemental intravenous agents such as opioids, ketamine, and a neuromuscular blocking agent. (See "Anesthesia for open pulmonary resection", section on 'Induction and maintenance'.)
Aortic embolic protection devices ineffective for cerebral protection during aortic valve surgery (August 2017)
Cerebral embolism of atherosclerotic or calcific debris from the ascending aorta or a left-sided cardiac valve may occur during cardiac surgery. Specialized aortic cannulae that incorporate embolic protection mechanisms are under investigation. In a randomized trial in over 375 patients at high risk for calcific emboli and undergoing valve replacement for aortic stenosis, three interventions were compared: a standard aortic cannula, an aortic cannula incorporating an intra-aortic filter, or a device for suction-based intra-aortic extraction of emboli . The incidence of postoperative clinical stroke, and the number or volume of cerebral infarctions detected by magnetic resonance imaging, did not differ among the intervention groups.(See "Cardiopulmonary bypass: Preparations and initiation", section on 'Aortic cannulation'.)
Five-year survival worse with off-pump compared with on-pump CABG (August 2017)
We perform off-pump coronary artery bypass graft surgery (CABG) in a small minority of patients as the evidence to support its use has been eroding. In the large ROOBY trial, the rate of death at five years was significantly higher with off-pump, compared with on-pump, CABG (15.2 versus 11.9 percent) . (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Outcomes", section on 'Comparison to on-pump CABG'.)
Home use of topical anesthesia to control pain from corneal abrasions (August 2017)
In a retrospective study of 444 patients with corneal abrasions given a 24-hour supply of topical tetracaine at the initial emergency department visit, there were no documented serious complications or uncommon adverse events . However, definitive outcomes were only known for 120 patients who returned for rechecks. Patients receiving topical tetracaine were more likely to return for emergency department reevaluation compared with patients who did not receive tetracaine. Topical analgesia was prescribed inappropriately in one-third of patients, for lesions other than simple corneal abrasion (eg, large corneal abrasions, retained rust rings, herpes keratitis, anterior uveitis, and corneal erosions). Because of the possibility of overuse (ie, use beyond 24 hours) and the risk of inappropriate administration, we favor other means of pain control and discourage the prescribing of topical anesthetic agents. More evidence is needed to establish the safety of this practice in patients with simple corneal abrasions. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Pain control'.)
Consensus guideline for managing spinal hypotension at cesarean delivery (December 2017)
An international expert panel of anesthesiologists has developed a consensus statement for the management of spinal hypotension during cesarean delivery . Important recommendations include prophylactic intravenous phenylephrine infusion titrated to maintain systolic arterial pressure ≥90 percent of baseline, left uterine displacement, and intravenous fluid coloading. (See "Anesthesia for cesarean delivery", section on 'Vasopressors'.)
Delayed respiratory depression after neuraxial morphine at cesarean delivery (November 2017)
The incidence of delayed respiratory depression after neuraxial morphine at cesarean delivery is unknown. In a prospective observational study of patients who received intrathecal morphine 150 mcg at cesarean delivery, a mild oxygen desaturation event (median peripheral arterial oxygen saturation [SpO2] <90 percent in a 30-second monitoring window) was detected in 23 percent, and a severe desaturation event (median SpO2 <85 percent) in 4 percent of patients . Desaturations most frequently occurred four to eight hours after administration of intrathecal morphine. Patients with risk factors for respiratory depression may require pulse oximetry monitoring for 24 hours after neuraxial morphine. (See "Anesthesia for cesarean delivery", section on 'Choice of spinal medication'.)
Intrapartum fluid administration (August 2017)
We provide maintenance intravenous fluids with glucose when intrapartum oral intake is restricted or otherwise inadequate to avoid volume depletion and ketosis. Some studies have suggested that a rapid intravenous fluid infusion rate or glucose supplementation are also associated with a shorter length of labor in such women. However, in one of the only trials to evaluate both interventions together, the length of labor was similar for women randomly assigned to 250 mL/hour of normal saline, 125 mL/hour of normal saline with dextrose, or 250 mL/hour of normal saline with dextrose . We do not adjust intravenous fluid administration to try to reduce labor duration. (See "Management of normal labor and delivery", section on 'Fluids and oral intake'.)
Left uterine displacement for cesarean delivery (July 2017)
Left uterine displacement is routinely used to avoid aortocaval compression during cesarean delivery, but the supporting evidence for this practice is not robust. In a trial that randomly assigned 100 healthy parturients having elective cesarean delivery to supine positioning or 15 degree lateral tilt, there was no difference in fetal acid base status . Blood pressure was maintained at baseline with intravenous fluid co-loading and phenylephrine in both groups. While these results raise a question of the need for left uterine displacement in healthy parturients, they may not apply to patients with uteroplacental insufficiency or to emergency procedures, and we continue to advise left uterine displacement for most women. (See "Anesthesia for cesarean delivery", section on 'Intraoperative positioning'.)
Neuraxial anesthesia in parturients with thrombocytopenia (June 2017)
The risk of spinal epidural hematoma (SEH) associated with neuraxial anesthesia (NA) techniques in patients with thrombocytopenia is poorly defined because SEH is rare. In a systematic review of over 1500 NA procedures in parturients with platelet counts less than 100,000 /microL, no cases of epidural hematoma requiring decompressive laminectomy were identified . A statistical analysis based on data from this cohort suggests that the incidence of epidural hematoma may range from 0.2 percent (for platelet counts 70 to 100,000/microL) to 11 percent (for platelet counts <49,000/microL). These estimates may inform clinical decision-making regarding performance of NA in parturients with thrombocytopenia. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics".)
New oral direct factor Xa inhibitor betrixaban approved (June 2017)
The US Food and Drug administration has approved a new oral direct factor Xa inhibitor, betrixaban, for venous thromboembolism prophylaxis in acutely ill medical patients . Betrixaban (brand name Bevyxxa) is taken at a dose of 160 mg on day 1 followed by 80 mg once daily for the duration of thromboprophylaxis. In a trial in which over 7500 patients hospitalized for an acute medical illness were randomly assigned to receive betrixaban or the low molecular weight heparin enoxaparin for 35 to 42 days, betrixaban was associated with a trend towards greater efficacy and a similar risk of bleeding compared with enoxaparin. (See "Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects" and "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".)
CDC guidelines for prevention of surgical site infection (June 2017)
The Centers for Disease Control published new guidelines for prevention of surgical site infection in May 2017; these update the prior guidelines published in 1999 . The guidelines state that administration of antibiotic prophylaxis should be timed such that a bactericidal concentration is present in tissue at the time of incision, additional antibiotic prophylaxis is not necessary after the surgical incision is closed, and intraoperative skin preparation should be performed with an alcohol-based antiseptic (unless contraindicated). Our recommendations are generally consistent with these guidelines. (See "Overview of control measures for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
External laryngeal manipulation during endotracheal intubation in children (December 2017)
In a retrospective study of data from an international registry of over 7800 infants and children undergoing endotracheal intubation in pediatric intensive care units, external laryngeal manipulation (ELM) was associated with lower first- pass successful intubation compared with no manipulation (59 versus 68 percent, respectively) . The difference remained significant after adjustment for potential confounders, although residual confounding may still contribute to this finding. ELM may improve the glottic view during laryngoscopy in selected patients (eg, children with anteriorly placed airways due to congenital anomalies or trauma patients with cervical spinal motion restriction in place), but routine use for endotracheal intubation in children does not appear to be beneficial. (See "Emergency endotracheal intubation in children", section on 'Adjusting for suboptimal view'.)
The Pediatric Sedation State Scale to assess pediatric procedural sedation (July 2017)
The Pediatric Sedation State Scale (PSSS) identifies six levels of sedation based on patient behavior (including patient interference with the procedure and need for restraint) and physiologic parameters (table 1). The PSSS is derived from expert opinion and has been validated, using a small sample of patients and observers, with high inter- and intra-observer agreement . Scales that simply measure the depth of sedation track only one aspect of this practice and do not assess key findings that identify whether the goals of procedural sedation are met. We suggest the use of the PSSS to provide a simple and rapid means of effectively documenting and communicating the quality of pediatric sedation. (See "Procedural sedation in children outside of the operating room", section on 'Sedation state'.)
PREOPERATIVE AND POSTOPERATIVE MANAGEMENT
Perioperative management of patients with skeletal dysplasia (November 2017)
Individuals with skeletal dysplasia, such as achondroplasia, are at increased risk for perioperative morbidity and mortality due to abnormalities of their upper airway, chest wall, and upper cervical spine. A new best practices report from a multidisciplinary, international expert panel has outlined recommendations for the perioperative management of these patients, with the goal of reducing complications and improving clinical outcomes . Recommendations include preoperative pulmonary, cardiac, and neurologic evaluations and imaging of the cervical spine. (See "Achondroplasia", section on 'Management'.)
Guidelines on the use of noninvasive ventilation for acute respiratory failure (September 2017)
The European Respiratory Society/American Thoracic Society issued guidelines on the use of noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) . Strong recommendations were made for the use of NIV in patients with acute exacerbations of chronic obstructive pulmonary disease who have hypercapnic acidosis and patients with acute cardiogenic pulmonary edema. Trials of NIV were suggested in other ARF populations, including patients who are immunocompromised, who have chest trauma, or who require palliative relief for dyspnea. These recommendations are consistent with previous UpToDate recommendations. (See "Noninvasive ventilation in acute respiratory failure in adults", section on 'Indications'.)
Oral fluid intake before anesthesia (August 2017)
Oral intake is generally restricted for two hours before anesthesia, but the volume of clear liquids that should be allowed before this deadline is unclear. In a study of patients who drank ≥2 liters of bowel preparation solution before colonoscopy, no difference in gastric residual volume or gastric pH was observed between those who finished the solution as late as three hours prior to the procedure versus those who finished it the night before . These data provide support for allowing patients free access to clear liquids until two hours prior to anesthesia and are particularly relevant to enhanced recovery after surgery protocols, which may include ingestion of 300 to 400 mL of carbohydrate drinks up to two hours prior to surgery. (See "Preoperative fasting guidelines", section on 'Clear liquids'.)
Perioperative medication management in rheumatic disease patients undergoing total hip or knee replacement (July 2017)
An expert panel of rheumatologists and orthopedic surgeons has developed guidelines for the perioperative management of various immunosuppressive medications in patients undergoing total hip or knee arthroplasty . In patients with rheumatic diseases, decisions must balance the potential risks of infection related to immunosuppressive medications with the risk of worsened disease control when medications are withheld. Important recommendations include that nonbiologic disease-modifying antirheumatic drugs (DMARDs) may be continued through the perioperative period, whereas biologic DMARDs should be withheld as close to one dosing cycle as scheduling permits prior to elective hip or knee replacement surgery. (See "Preoperative evaluation and perioperative management of patients with rheumatic diseases", section on 'Medication management'.)
Confirmatory data on idarucizumab for dabigatran reversal (July 2017)
Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding . We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)
Comprehensive geriatric assessment before elective vascular surgery (June 2017)
Older adults undergoing vascular surgery have a high incidence of medical co-morbidities that increase the risk for perioperative morbidity and mortality. In a trial that compared comprehensive geriatric versus standard preoperative assessment in patients at least 65 years old undergoing major elective vascular surgical procedures, comprehensive geriatric assessment reduced postoperative complications and length of stay, with a trend toward fewer discharges to a higher level of dependency . This trial underscores the need to accurately assess medical risk prior to undertaking elective vascular surgery in older adults. (See "Overview of lower extremity peripheral artery disease", section on 'Revascularization'.)
Choice of regional anesthesia for severe rib fractures (July 2017)
Whether there is a preferred form of regional anesthesia for managing refractory pain due to severe rib fractures is unknown. A large retrospective study that compared outcomes of epidural analgesia versus paravertebral block in over 2000 patients with multiple rib fractures observed similar rates of in-hospital mortality, length of stay, pneumonia, intensive care admission, use and duration of mechanical ventilation, and other complications . Thus, either technique appears to be a reasonable analgesic option for rib pain refractory to oral and parenteral therapy. (See "Inpatient management of traumatic rib fractures", section on 'Regional anesthesia'.)
SURGICAL CRITICAL CARE
Guidelines for mechanical ventilation in patients with ARDS (August 2017)
Guidelines were issued by the American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine for mechanical ventilation strategies in patients with acute respiratory distress syndrome (ARDS) . Key aspects included recommendations in favor of the use of low tidal volume ventilation (all ARDS patients) and prone positioning (severe ARDS). They also promoted the use of high levels of positive end expiratory pressure (PEEP) and recruitment maneuvers in select patients and recommended against the use of high frequency oscillatory ventilation (HFOV). No recommendations were made on the use of extracorporeal membrane oxygenation. (See "Prone ventilation for adult patients with acute respiratory distress syndrome" and "High-frequency ventilation in adults" and "Extracorporeal membrane oxygenation (ECMO) in adults" and "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Low tidal volume ventilation'.)
Asymptomatic cervical spine fracture in older adults with trauma (August 2017)
Under-triage and unrecognized injuries remain a major problem in the management of elder trauma patients. Both the history and the physical examination are often less sensitive for detecting injuries in older trauma patients compared with their younger counterparts. In a recent retrospective study of 173 patients over the age of 55 with cervical spine fractures identified on diagnostic imaging, 36 (21 percent) reported no neck pain and no midline cervical tenderness at presentation . All patients had a Glasgow Coma Score of 15. We continue to advocate for a low threshold for obtaining advanced imaging studies in older trauma patients at risk of injury. (See "Geriatric trauma: Initial evaluation and management", section on 'Cervical spine injury'.)
Vasopressor blood pressure targets in critically ill patients with shock (July 2017)
Hemodynamic support with continuous infusion of a vasopressor agent may be necessary in patients with shock if administration of intravenous fluids fails to restore adequate blood pressure and/or tissue perfusion. In a systematic review of two randomized trials that included 894 critically ill adults with hypotension requiring vasopressor therapy, higher mean arterial pressure (MAP) target values (80 to 85 mmHg in one trial and 75 to 80 mmHg in the other) did not result in a mortality benefit and increased the risk of cardiac arrhythmias, compared with lower targets (65 to 70 mmHg and 60 to 65 mmHg) . We suggest a target MAP of 65 to 70 mmHg, rather than a higher target, in critically ill adults with hypotension who require vasopressor support. Similar MAP target values were recommended in a recent guideline of the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) . (See "Intraoperative management of shock in adults", section on 'Initial interventions'.)
Stress ulcer prophylaxis in critically ill patients (June 2017)
The benefits and harms of stress ulcer prophylaxis in critically ill patients have recently been questioned, with concerns about possible increased risk of pneumonia and Clostridium difficile infection associated with use of proton pump inhibitors (PPIs). A preliminary randomized trial in 91 patients reported no difference in the rate of upper gastrointestinal bleeding, pneumonia, or C. difficile infection in mechanically ventilated receiving pantoprazole (a PPI) or placebo . Also included as part of the study was a meta-analysis of five trials comparing PPIs to placebo that reported no difference in the rates of bleeding, infections, or mortality. These data justify the feasibility of larger placebo-controlled trials to replicate these findings before revising recommendations for stress ulcer prophylaxis in critically ill patients. (See "Stress ulcer prophylaxis in the intensive care unit", section on 'Efficacy'.)
Angiotensin II as an investigational vasopressor agent in shock (August 2017)
A randomized trial investigated the safety and efficacy of angiotensin II as a vasopressor agent for patients with vasodilatory (mostly septic) shock . For patients receiving high-dose norepinephrine, the trial compared the addition of angiotensin or placebo.The increase in mean arterial pressure (MAP) was greater in the angiotensin II group. As well, less norepinephrine was required in the angiotensin II group and there was no difference in serious adverse events between the groups. These results are encouraging, but further trials are indicated to determine the role of angiotensin II for the treatment of vasodilatory shock. (See "Use of vasopressors and inotropes", section on 'Angiotensin II'.)
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