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New Crucial Literature: The Science You Need to Know

Study Examines Long-Term Elevated Cardiovascular Risks Associated with New-Onset AF after Noncardiac Surgery

Siontis KC, Gersh BJ, Weston SA, et al. Association of New-Onset Atrial Fibrillation After Noncardiac Surgery With Subsequent Stroke and Transient Ischemic Attack. JAMA. 2020;324(9):871-878.

The authors queried a single-county medical database to determine long-term consequences of new-onset atrial fibrillation occurring within 30 days of a major noncardiac operative procedure performed after admission to hospital under general anesthesia using open or minimally invasive techniques. Outcomes data on 550 patients who underwent procedures between 2000 and 2013 were analyzed. Patients were excluded if they had a history of prior AF or underwent cardiothoracic surgical procedures. Median follow-up was 5.6 years. The data analysis showed that patients who developed postoperative AF were more likely to have a history of cardiovascular disease and/or diabetes using standard scoring systems. Postoperative AF was associated with significant elevated risk for stroke or transient ischemic attack during the follow-up interval.

The potential benefits of differing forms of management of postoperative AF and the use of anticoagulation therapy are unknown and additional data are needed to determine optimal means of prevention and long-term treatment of postoperative AF.

New Study Explores the Future of Resuscitation of Hemorrhagic Shock

Chipman AM, Jenne C, Wu F, Kozar RA. Contemporary resuscitation of hemorrhagic shock: What will the future hold? Am J Surg. 2020;220(3):580-588.

Chipman and coauthors provided a clear and thorough review of risks and potential benefits of current approaches to the management of hemorrhagic shock; these approaches currently emphasize the use of early red blood cell, platelet and plasma transfusion. The review noted that the evolution of resuscitation protocols away from the use of balanced electrolyte solutions and toward current practice has resulted in improved mortality rates and lower risk of organ failure.

Nonetheless, risks of current therapies include transfusion reactions and organ injury (transfusion-related acute lung injury or TRALI). In addition, blood, platelets, and plasma are subject to shortages and increased expense due to required donor recruitment and costs of preservation and storage. An additional risk is transmission of disease in donated blood products. The authors cited recent data that have raised concerns over the risks of COVID-19 transmission via transfusion of blood, plasma and platelets. New initiatives to reduce pathogen transmission include treatment with solvent/detergent agents and the use of ultraviolet radiation. Storage techniques and approaches to reduce contamination of blood products are reviewed in detail.

The authors concluded that efforts to improve storage and reduce the risks associated with blood, platelet, and plasma transfusion will improve availability of these agents and lead to additional improvements in outcomes of treatment for hemorrhagic shock.

Viewpoint Article Discusses Evolving Understanding for Tracheostomy Timing for Severely Ill COVID-19 Patients

Schultz MJ, Teng MS, Brenner MJ. Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times. JAMA Otolaryngol Head Neck Surg. 2020.

This viewpoint article reviews current perceptions of the clinical course of COVID-19 infection that influence clinicians’ understanding of the need for and timing of tracheostomy for patients with pulmonary insufficiency requiring ventilator therapy. The article noted that early studies had suggested that tracheostomy be delayed until 21 days or more of ventilator therapy were required; this approach was prompted by concerns over the risk of transmission of the virus to health care workers. Newer therapeutic approaches (prone positioning for improvement of oxygenation, for example) and improved understanding of transmission risks have led to current recommendations that timing of tracheostomy be individualized. Newer data have shown that prone positioning is more useful if used with conventional intubation rather than tracheostomy. Additional data now support the use and safety of percutaneous tracheostomy. The authors emphasized the fact that randomized, prospective trials to clearly define optimum timing and technique for the safest, most effective use of tracheostomy are not available and probably never will be performed. For this reason, careful evaluation of observational studies and detailed knowledge of local data concerning outcomes of tracheostomy and rates of transmission of infection to health care workers are essential for patient and health care worker safety.

Dual Benefit? Perspective Article Explores Potential for Masks to Protect Others and Build Immunity to COVID-19

Gandhi M, Rutherford GW. Facial Masking for Covid-19—Potential for "Variolation" as We Await a Vaccine. N Engl J Med. 2020.

This perspective article explores data suggesting that face masking not only protects nearby individuals from aerosols from mask wearers but also may protect the wearer by reducing exposure to airborne viral particles; the lower viral load that mask wearers are exposed to can lead to an increased proportion of asymptomatic infections. These infections can produce immunity without causing symptomatic infection and could lead to more rapid control of the virus on a population level. This noteworthy hypothesis is another reason to encourage universal mask wearing.

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