Predictors of postoperative cognitive dysfunction

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Predictors of Postoperative Cognitive Dysfunction

For adults aged 65 years or older presenting for ambulatory surgery, 1 in 6 have preexisting cognitive impairment. There is a higher prevalence of cognitive impairment in patients with the following characteristics: Age over 85 years, Male Lower s

For adults aged 65 years or older presenting for ambulatory surgery, 1 in 6 have preexisting cognitive impairment. There is a higher prevalence of cognitive impairment in patients with the following characteristics:

  • Age over 85 years, Male

  • Lower socioeconomic and education levels

  • History of stroke

  • Preoperative functional dependence

Although ambulatory surgery confers a lower risk of developing perioperative neurocognitive dysfunction than major procedures, these preexisting patient risk factors are more predictive.

FDA Approves New Opioid With Less Respiratory Depression And Addiction Potential Than Morphine and Why it is important

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FDA Approves New Opioid With Less Respiratory Depression And Addiction Potential Than Morphine and Why it is important

A top level FDA official said: “Addressing the opioid crisis remains a top priority for the FDA,” per Dr Douglas Throckmorton, deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research.

Oliceridine is a full opioid agonist and is relatively selective for the mu-opioid receptor. It is indicated for short-term IV use in hospitals and other controlled clinical settings. Following an initial dose, the onset of analgesic effect is expected within 2 to 5 minutes.

The key to Oliceridine’s Improved respiratory profile is key and important here. This has the potential for being a breakthrough. Despite using the same mu receptors as Morphine, Oliceridine owes this improvement in its separate secondary pathway massager system it uses once the mu receptor becomes activated.

Oliceridine is G-Protein Biased mu receptor agonist. While morphine is an unbiased agonist morphine and uses the cyclic AMP (cAMP) cascade. The differences are as result of how ‘mechanically” Morphine and Oliceridine each bind the G-Protein receptors. This specific binding can be further studied to target more favorable safety profiles in opioids even further in the future.

Aside from reduced respiratory depression, G-protein-biased agonists such as oliceridine may reduce opioid maladaptations and enhance the quality of surgical recovery.

Studies also have shown that Oliceridine as compared to pother narcotics decreased narcotic seeking behavior in rats. These researchers Proposed that: “ G protein-biased mu opioid receptor agonists should be considered as relapse prevention maintenance treatment for opioid addiction.”

This great science resulting in a potentially much improved opioid analgesic.

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Povidone-Iodine as Nasal and Mouthrinse Proves Effective In Reducing Transmission of COVID-19

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Povidone-Iodine as Nasal and Mouthrinse Proves Effective In Reducing Transmission of COVID-19

To reduce transmission for the front-line health care provider, use of a prophylactic nasal spray and oral mouthrinse may be a useful approach. Povidone-iodine (PVP-I) is a widely available broad-spectrum antiseptic with potent antiviral, antibacterial and antifungal activity. It is commonly used in clinical settings for skin disinfection before and after surgery. In vitro studies support its use against COVID-19, MERS-CoV, H1N1 influenza and rotavirus with good efficacy. It has been shown to be an effective therapy when used as a mouthwash or intranasally. In addition, 0.2% PVP-I solution has been shown to be safe when administered intranasally and as a mouth-rinse.

The American Dental Association has published guidelines for minimizing transmission of COVID-19, which includes the use of a preoperative 0.2% PVP-I mouthwash. The aim is to reduce the viral “load” from key areas from where virus-containing droplets are aerosolized. Researchers have reported significantly reduced viral load lasting for up to four hours following intranasal and mouth-rinse.

A 1% PVP-I solution is usually available in preoperative areas and could be diluted with saline (1 cc of PVP-I with 20 cc of saline for an approximate 0.2% solution). Patients would be asked to gargle for 30 seconds before expectorating into a basin. Additionally, a buffered saline solution containing 0.2% PVP-I could be administered intranasally before an aerosolizing event like dental procedure or intubation

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Being comforting decreases patient's pain - Findings show courtesy during blood draws provides 400% benefit

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Being comforting decreases patient's pain - Findings show courtesy during blood draws provides 400% benefit

Having blood drawn by a courteous health care provider can really take the sting out of those procedures, suggests a study in 2019 ASA meeting.

In fact, an empathetic provider - one who asks about patients' previous experiences with needles and takes their preferences into account - could make all the difference when it comes to pain management. Patients in the study were 390% more likely to say their pain was well-controlled when the person taking their blood was courteous, the researchers found.

Researchers set out to assess whether more blood draws would increase the pain experience and then determine if health care worker courteousness would ease the discomfort of a higher number of needle sticks.

Researchers analyzed responses from 4,740 adult patients about their experience when they were hospitalized, specifically two questions about pain control and one statement about the courtesy of the person who drew their blood.

For the two pain-related questions, patients answered from 1 (never) to 4 (always). Researchers determined that 3,882 of the 4,740 patients (82%) answered 4 when asked how often the staff did everything they could to help them with their pain and 3,112 (65%) answered 4 when asked how often their pain was well-controlled.

Patients were separately asked to rate the courtesy of the person who took their blood from 1 (very poor) to 5 (very good). Researchers found those who answered 5 were 390% more likely to have rated their pain control as a 4 (the maximum), than those who rated their provider less courteous.

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Know Anyone Suicidal? This anesthetic can help

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Know Anyone Suicidal? This anesthetic can help

For years the last step of treatment for those with responsive to antidepressants was Electroconvulsive Treatment (ECT) until Ketamine. A very unique drug that has both hypnotic and analgesic properties, it was found that when given as an IV infusion over 40 minutes it would treat depression in many patients within 3 days. Ketamine’s efficacy is equal to that of ETC. The standard dosing regimen to give it has been in IV infusion given in 2-3 different sessions. The dose is considered subclinical as compared to the normal anesthetic does with almost no side effects. So it is obvious how this has been a breakthrough as compared to ETC which is brutal in nature.

Recently, the FDA approved Esketamine, a ketamine-like drug in a nasal spray for use as fast-acting relief, but Johnson & Johnson, the company that developed Esketamine, has only done four efficacy studies of mixed results. Esketamine isn't ketamine: it's a mirror-image of the ketamine molecule ("left-handed ketamine," or "S-for-sinister-ketamine").

However it appears that the IV form of ketamine is still the better option than the new intranasal form. Ketamine works great for depression and other conditions, and costs $10/dose; the new FDA-approved "ketamine" performs badly in trials and costs a fortune.

More studies are underway and many new antidepressants will mimic the mechanism of actions by which ketamine works.

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Cannabis Use on Sedation Requirements

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Cannabis Use on Sedation Requirements

Cannabis use has increased in the United States by 43% between 2007 and 2015.

A retrospective study published on The Journal of the American Osteopathic Association has shown significant anesthetic requirements in Cannabis using patients.

More patients are using cannabis, and more patients are now willing to admit cannabis use than in the past, which increases the likelihood that they will be forthcoming about use during medical questioning.

Hypotheses have been proposed that tetrahydrocannabiol interacts with specific cannabinoid receptors, which could include opioid and benzodiazepine receptors, among other mechanisms of pharmacologic action.3 Thus, the interaction of opioids or benzodiazepines with these receptors in patients who regularly use cannabis may be altered. 

The study of 250 patients showed significant increases in anesthetic needs during endoscopies for several anesthetics as shown below:

Midazolam Increase by 20 percent

Fentanyl increase by 14 percent

Propofol Increase by 220 percent

One limitation of this study was that it was a retrospective medical record review that consisted of data collection and analysis.

Three other articles have shown similar patterns. Two were single patient case studies, 1 in Pakistan in 2014 and 1 in Berlin in 2015. The Pakistan case study found a possible association with cannabis use and the need for increased anesthesia; the patient was switched from propofol to thiopental for induction of anesthesia when he did not respond to the propofol after a total dose of 300 mg. The Berlin case study also found an increased need for anesthesia, in particular, propofol and morphine.

One Australian study from 2009 reviewed the induction dose of propofol required in patients using cannabis and compared 30 users with 30 nonusers. The research concluded that cannabis use increased the need for propofol during anesthesia when inserting a laryngeal mask. 

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Dental claims continue to be the No. 1 anesthesia-related claim reported by PPM policyholders

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Dental claims continue to be the No. 1 anesthesia-related claim reported by PPM policyholders

Perioperative dental injuries are a known risk and complication and infrequently caused by clinical negligence. However, many patients who experience dental injury assume the anesthesia provider was negligent and should be responsible for payment for dental consultation and repair.

Identifying Patient Risk Factors

The risk is significantly greater if the patient existing periodontal disease, poor dentition, dental restorations.  Other risk factors are history difficult intubation, Limited neck ROM, History of head neck surgery or abnormalities.

Avoiding Iatrogenic Causes of Dental Injury

Various anesthetic devices, especially rigid devices, can cause dental injury. The following devices are frequently associated with dental injury and should be used with caution:

  • Laryngoscope: Upper incisors can be damaged if force is applied to the teeth by the laryngoscope blade using the upper teeth as a fulcrum

  • Oropharyngeal airways: Can cause injury during extubation as the patient might involuntarily bite down on the airway and it can act as a fulcrum causing injury

  • Jaw clamping: Use of a jaw clamp during light anesthesia, particularly when used with an oropharyngeal airway, can put pressure on the teeth

  • Bite blocks: Wrong placement of bite block can cause damage to the anterior teeth

  • Suction devices: Dental injuries can be caused when anterior teeth are subjected to extreme lateral force

  • Dental props and mouth gags: Can damage teeth during insertion or removal or when they are moved from one side of the mouth to the other 4

Preanesthesia Evaluation and Documentation

The evaluation should include the patient’s dental history, oral and dental examination, and a specific discussion with the patient about any existing dental conditions that might increase the risk for dental injury. The dental examination should also include a focused assessment of the patient’s upper incisors, which are the most commonly involved teeth in dental injuries. Patients with existing dental problems should be advised that they are at increased risk for dental injury. Patients with existing bridges, caps, crowns or veneers are particularly susceptible to injuries, which frequently require expensive repairs. Removable dental work such as dentures or bridges should be removed preoperatively.

Informed Consent

Documentation of the risk of dental injury in both the preoperative notes and on the informed consent is key and helps to establish reasonable patient expectations and diminishes the perception of medical negligence.

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Dental Office Receptionist steals over $600,000 from dentist- A note to be vigilant

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Dental Office Receptionist steals over $600,000 from dentist- A note to be vigilant

A woman who worked as a receptionist and bookkeeper for an Arlington Heights dentist was charged with aggravated identity theft, financial fraud and theft for, authorities allege, stealing more than $600,000 from her employer over about six years beginning in 2009.

The checks, made out to the dental practice, came from 98 different insurers and dozens of patients. Each bore the endorsement of the dentist, who told authorities he did not sign any of the checks.

The defendants cashed the checks at currency exchanges, a gas station and a local bar or deposited them in a bank account, adding "it is believed the money was used for a variety of things."

An internal review showed "inconsistencies between accounts received and insurance reports," Crothers said. The dentist eventually discovered The receptionist had failed to deposit 1,464 checks totaling $625,526.23, she said.

She and her husband have been arrested with $600,000 bond and in trial.

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General Anesthesia Before Primary School Not Found to Harm Child Development : Study of Siblings

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General Anesthesia Before Primary School Not Found to Harm Child Development : Study of Siblings

According to a recent retrospective analysis of more than 10,000 sibling pairs at the University of Toronto, exposure to surgery and anesthesia before entry into primary school did not increase the risk for adverse developmental outcomes compared with biological siblings who did not undergo surgery. (1)

The findings of a sibling-matched cohort study should reassure parents of young children that anesthesia for surgical procedures is safe at early ages at least in single cases of short duration.

Most children in the current study who were exposed to general anesthetic drugs had a single surgery performed that typically did not require lengthy exposure to anesthesia. Larger sample populations may be required to detect potentially small differences in child development outcomes.

The research was published in JAMA Pediatrics (2018. doi: 10.1001/jamapediatrics.2018.3662. 

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Simplified OSA Screening Tool-Instead of the STOP-BANG

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Simplified OSA Screening Tool-Instead of the STOP-BANG

Called the BOSTN screening tool and it is composed of five separate patient characteristics, each of which is allotted 1 point if present:

Body mass index of 30 kg/m2 or greater;

Observed apnea;

Snoring that is loud;

Tiredness in the daytime; and

Neck circumference of 16.5 inches or greater in females and 17.5 inches or greater in males.

Patients who score 2 points or more are classified as high risk for OSA.

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