Perioperative Methadone for Spine Surgery: A Scoping Review.

Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.

The Considerations and Controversies in Using High-Flow Nasal Oxygen with Self-Prone Positioning in SARS-CoV-2 COVID-19 Disease.

Evidence exists for the use of high-flow nasal oxygen (HFNO) in the general critical care population for acute hypoxemic respiratory failure. There is discord between guidelines for hypoxemia management in COVID-19. Both noninvasive management and intubation present risk to patients and staff and potentially overwhelm hospital mechanical ventilator capacity. The use of HFNO has been particularly controversial in the UK, with oxygen infrastructure failure. We discuss our experience of managing COVID-19 with HFNO and awake self-prone positioning. We focus upon the less-usual case of an eighteen-year-old female to illustrate the type of patient where HFNO may be used when perhaps earlier intubation once was. It is important to consider the wider implications of intubation. We have used HFNO as a bridge to intubation or as definitive management. As we await clinical trial evidence, HFNO with self-prone positioning has a role in COVID-19 for certain patients. Response parameters must be set and reviewed, oxygen infrastructure considered, and potential staff droplet exposure minimised.

Leukoreduced blood transfusion does not increase circulating soluble markers of inflammation: a randomized controlled trial.

BACKGROUND: Transfused blood may have immunomodulatory and proinflammatory effects. We report the first randomized study exploring whether leukoreduced red blood cell (RBC) transfusion increases circulating proinflammatory mediators, markers of neutrophil activation, and the acute-phase response in critically ill adults. STUDY DESIGN AND METHODS: Eighty-four patients were recruited from six general intensive care units in the United Kingdom as part of a laboratory study nested within a parallel-group randomized trial comparing restrictive and liberal leukoreduced RBC transfusion strategies in critically ill patients aged more than 55 years with measured hemoglobin concentrations of not more than 90 g/L (ClinicalTrials.gov NCT00944112). Forty-one patients received transfusion and 43 did not receive transfusion. Plasma was sampled at baseline, 6 hours, and 24 hours after randomization or transfusion, and concentrations of interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12-p70, interferon-γ, tumor necrosis factor-α, human neutrophil elastase, soluble L-selectin, and C-reactive protein were measured using cytokine bead array analysis and an enzyme-linked immunosorbent assay. RESULTS: Patients who received transfusion did not have significantly different inflammatory biomarker plasma concentrations at the time points compared to those who did not receive transfusion, with the exception of IL-8 concentrations at 24 hours, which were reduced in the transfused group (p = 0.02). After adjustment for baseline inflammatory biomarker concentrations, there were no significant differences between patients who received transfusion and those who did not. CONCLUSION: Concentrations of measured biomarkers were not significantly increased during the first 24 hours after leukoreduced RBC transfusion. These data do not support the contention that leukoreduced RBC transfusion is associated with a proinflammatory response in the general adult critically ill population.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Using the ultrasound compression test for deep vein thrombosis will not precipitate a thromboembolic event.

A short cut review was carried out to establish whether patients with deep vein thrombosis (DVT) are at risk of embolism during ultrasound compression testing. No papers were found that directly answered the clinical question. The clinical bottom line is that currently there is no evidence to suggest that compressing vessels in order to identify a DVT could cause an embolic event. Therefore we can consider ultrasound assessment a safe reliable investigation for the diagnosis of DVT with no evidence of causing harm.