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TITLE: Goal-directed hemostatic therapy for severe bleeding (in three parts) LINKS: https://ronlitman.substack.com/p/goal-directed-hemostatic-therapy; https://ronlitman.substack.com/p/goal-directed-hemostatic-therapy-413; https://ronlitman.substack.com/p/goal-directed-hemostatic-therapy-a12 Original review article: Crochemore T, Görlinger K, Lance MD. Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review. Anesth Analg. 2024 Mar 1;138(3):499–513. doi: 10.1213/ANE.0000000000006756. Epub 2024 Feb 16. PMID: 37977195; PMCID: PMC10852045. Crochemore et al. integrate the current understanding of coagulation and hemostasis, therapies that are effective in controlling bleeding, and laboratory testing that guides those therapies. The recommendations are supported by numerous references on the efficacy of both testing and therapies. The authors propose a ten-step approach to bleeding, of which eight of the steps are blood tests. The core is viscoelastic testing that has been refined since its introduction in 1948. Dr. David Jobes in this review adds that clinicians must replace lost blood continuously to sustain adequate perfusion and may not be able to wait for a laboratory test result to direct treatment. With severe losses, the use of fresh whole blood initially may be optimal. TITLE: Beyond Survival: Focus on Improving Neurodevelopmental Outcomes For Patients with Congenital Heart Disease LINK: https://ronlitman.substack.com/p/beyond-survival-focus-on-improving Original article: An American Heart Association Scientific Statement Sood E, Newburger JW, Anixt JS, Cassidy AR, Jackson JL, Jonas RA, Lisanti AJ, Lopez KN, Peyvandi S, Marino BS; American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young and the Council on Cardiovascular and Stroke Nursing. Neurodevelopmental Outcomes for Individuals with Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management: A Scientific Statement From the American Heart Association. Circulation. 2024 Feb 22. doi: 10.1161/CIR.0000000000001211. Epub ahead of print. PMID: 38385268. As a result of advancements in medical and surgical care, more than 90% of patients with even the most complex congenital heart disease (CHD) survive to adulthood. The quality of survival, particularly of neurodevelopmental outcomes has moved to the forefront of medical research and clinical practice. This update to the 2012 American Heart Association Scientific Statement is intended to inform practitioners caring for patients with CHD of the current state of knowledge of neurodevelopmental outcomes in this high-risk population. Best practices for risk stratification, neuroprotection, evaluation, and management of developmental delays and disorders are delineated. TITLE: A New Era in Malignant Hyperthermia LINK: https://ronlitman.substack.com/p/a-new-era-in-malignant-hyperthermia Original article: Yu KD, Betts MN, Urban GM, Schwartz MLB, Robinson TO, Moyer RJ, Taddonio SW, Vasudevan A, Johns A, Sturm AC, Kelly MA, Williams MS, Poler SM, Buchanan AH. Evaluation of Malignant Hyperthermia Features in Patients with Pathogenic or Likely Pathogenic RYR1 Variants Disclosed through a Population Genomic Screening Program. Anesthesiology. 2024 Jan 1;140(1):52–61. doi: 10.1097/ALN.0000000000004786. Erratum in: Anesthesiology. 2024 Feb 20. PMID: 37787745. Original article: Yu H, Tan L, Deng X. Improving Dantrolene Mobilization in Regions with Limited Availability. Anesthesiology. 2024 Feb 8. doi: 10.1097/ALN.0000000000004892. Epub ahead of print. PMID: 38329334. The availability of the halothane caffeine contracture test, the definitive test to diagnose MH, US has all but disappeared in the United States because of the cost of maintaining the testing centers and the invasive nature of the procedure. There are now only three testing centers in the USA, and one is primarily for the military. Advances in genetics are guiding care in many areas of medicine and pharmacology including the diagnosis of MH. Indeed, over the past 10 years, work on the genetics of MH has shown that three genes contain DNA variants that are causal for the disorder (RYR 1, CACNA1S, and STAC 3). TITLE: Perioperative acetaminophen (paracetamol): Why burn money? LINK: https://ronlitman.substack.com/p/perioperative-acetaminophen-paracetamol Original article: Mahon RM, Rajbhandari P, Brown TA, Engler LJ, Bhalla T. Improving perioperative acetaminophen administration for safer and cost-effective multimodal analgesia in pediatric surgery: A QI initiative. Paediatr Anaesth. 2024 Apr 5. doi: 10.1111/pan.14893. Epub ahead of print. PMID: 38578161. Multimodal analgesia (MMA), in theory, optimizes perioperative pain control and reduces the overreliance on opioids and opioid-induced side effects. Multiple classes of systemic analgesic medications are used to accomplish this including acetaminophen, NSAIDs, local anesthetics, NMDA antagonists, and the gabapentinoids to name a few. Regional anesthetic techniques and nonpharmacologic techniques like using virtual reality are also invaluable tools. Acetaminophen is one of the essential building blocks of MMA and is equally effective regardless of the method of administration. Obviously, the oral (and rectal) routes are significantly less expensive the IV formulation. In this quality improvement study, the authors increase the use of oral administration through the institution using the model for improvement methodology. TITLE: Pediatric Anesthesiology and Children who Die LINK: https://ronlitman.substack.com/p/pediatric-anesthesiology-and-children Original article: Linebarger JS, Johnson V, Boss RD; SECTION ON HOSPICE AND PALLIATIVE MEDICINE; Linebarger JS, Collura CA, Humphrey LM, Miller EG, Williams CSP, Rholl E, Ajayi T, Lord B, McCarty CL. Guidance for Pediatric End-of-Life Care. Pediatrics. 2022 May 1;149(5):e2022057011. doi: 10.1542/peds.2022-057011. PMID: 35490287. Fortunately, unexpected intraoperative death is rare in pediatric anesthesia—though still too common! Caring for children at the end of life and the families that grieve them is an important element of pediatric anesthesia practice. It is a privilege and an honor, adds meaning to our work, and makes us proud when done well. For the pediatric anesthesiologist, understanding the path that led a child and family to our operating room helps inform the family's concerns, values, and goals—which leads to improved anticipation and response to clinical scenarios. The principle involved in the care of these children is critical reading to ensure that pediatric anesthesiologists are prepared the next time this situation presents itself in the perioperative environment.
Peterson et al. (Thu,) studied this question.