Collins et al share their insights from 10 years of Cardiff research and pragmatic clinical experience managing postpartum hemorrhage.
Why is this important?
PPH incidence is increasing globally and is still the number one cause of maternal death. Many routine PPH transfusion practices are dogmatic and based upon non-pregnant trauma data. Applicability to PPH is at best questionable.
Of interest they note:
- The utility of fibrinogen measurement as an early indicator of coagulopathy and severe PPH, especially <2 g/L.
- The value of point-of-care testing, such as with ROTEM®.
- The typical maintenance of normal PT & APTT until 4-5 L of blood loss, unlike fibrinogen which was abnormal after ~2 L loss.
- The rarity of needing to replace factors other than fibrinogen even in severe PPH. FFP can usually be safely withheld in moderate-to-severe PPH when POCT is available.
- The value of fibrinogen concentrate over cryoprecipitate, although without value in pre-emptive formulaic treatment.
- The value and practicality of measuring blood loss versus estimation.
The take-away: Plasma fibrinogen is generally a more important target than PT or APTT in most PPH cases. (Placental abruption is an important exception.)
Interesting physiological tidbit... because normal term fibrinogen is 4 g/L and FFP fibrinogen is 2 g/L, undirected FFP transfusion in PPH could theoretically contribute to dilutional hypofibrinogenemia.
An interesting exploration of the surgeon-anesthesiologist relationship, framed in terms of it being the critical dyad of the operating theatre team.
Cooper explores the positives and negatives, the stereotypes that each craftgroup holds of the other, and the ways in which these translate to team performance.
Most significantly, Cooper makes the point that when highly functional this relationship can lead to the highest quality patient care, but at its worst, dysfunction can lead to extreme harm and compromise patient safety.
The surgeon-anesthesiologist relationship is probably the most critical in determining overall team performance.
Cutting to the chase...
This large, retrospective study with propensity-matched controls found NO difference in breast cancer survival between inhalataional and intravenous anesthetic techniques.
Why is this still important?
Following Exadaktylos' eye-popping 2006 retrospective, along with a few in vitro studies, anesthetists have been a little anxious that anesthetic technique choice could potentially have a such significant effect on cancer recurrence. To date, other trials have not replicated Exadaktylos' original results.
What was studied this time?
Yoo et al performed a retrospective study of 5,331 breast cancer patients over a 8 year period, looking at the relationship between anesthetic technique and both 5-year recurrence-free and overall survival.
There was no difference for either survival metric between inhalational or intravenous anesthesia.
So does this settle it?
Not yet. Although large and high quality, this is still a retrospective study with all the compromises that this brings.
While we await results from prospective, randomized trials, we should not be distracted by the magical promise of one technique over another, and instead address the very real impact that anesthesia can have on patient Return to Intended Oncological Therapy (RIOT).
This controversy-starting retrospective study reported a 30% reduction in 3 year recurrence-free survival after undergoing mastectomy for primary breast cancer in patients who received a traditional general anaesthetic with morphine analgesia, compared with those receiving a regional (paravertebral) technique.
Although plausible biological mechanisms have been suggested and even demonstrated in vitro, the huge treatment effect is yet to be replicated in better quality retrospective or prospective trials.
Evidence to date does not (yet) support this trial’s findings.
"An extraordinary claim requires extraordinary proof." – Marcello Truzzi
In traumatic brain injury resuscitation with albumin is associated with a higher mortality than resuscitation with saline.
ICU resuscitation with either normal saline or 4% albumin results in similar outcomes, in the absence of traumatic brain injury.
High troponin levels pre-operatively are associated with cardiac events and mortality after non-cardiac surgery.
Elective surgery should be delayed at least 9 months after stroke or cerebrovascular event, although there is a persisting increased risk of perioperative stroke in these patients.