Month: August 2019

Early Acute Kidney Injury and Outcome in Acute Respiratory Distress Syndrome

The authors carried out a secondary analysis of an observational study. Patients with severe respiratory failure were categorized based on worst serum creatinine or urine output.

Highlighting the significance of renal dysfunction, they concluded: The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.


Maternal Dissatisfaction and Anesthesia Care

Maternal dissatisfaction was studied in this retrospective study after vaginal or Cesarean delivery.

Maternal dissatisfaction was associated with: pain intensity during the first stage of labour; pain intensity during the second stage of labour; postpartum pain intensity; delay > 15 min in providing epidural analgesia and postpartum headache, pruritus. Non‐Hispanic ethnicity was negatively associated with dissatisfaction. After caesarean delivery, the intensity of postpartum pain, headache and pruritus were linked to dissatisfaction. Hispanic ethnicity also had a negative relationship with dissatisfaction after caesarean delivery.

The lessons learnt should spur timely provision of analgesia at all phases of the delivery process and efforts to minimize and treat side effects.

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Occipital Neuralgia and Greater Occipital Nerve Blocks

Occipital neuralgia is a cause of occipital headache and is amenable to nerve block techniques.

This article discusses the symptomatology and in particular the use of ultrasound in the use of occipital nerve block.

It concludes: “Ultrasound-guided occipital nerve blocks appear to be a relatively safe, effective, and easy procedure for both the diagnosis and treatment of occipital neuralgia…more targeted blocks and potentially allowing for denervation procedures in the future”

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Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant

Many differing regimes have been recommended by different organizations as well as those using different direct oral anticoagulants (DOACs) based on their half life and renal function.

A simple regime was employed, largely amounting to interruption of DOACs 1 day before low bleeding procedures or 2 days before high bleeding risk procedures, with an adjustment for moderate renal dysfunction for Dabigatran. Resumption occurred in 1 day with low bleeding risk and 2 – 3 days with higher bleeding risk.

Conclusion: “A simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of major bleeding and arterial thromboembolism.“

How this meshes with regional or neuraxial anesthesia guidelines as in ASRA is open to further discussion.


Emergency Department to ICU Time and Hospital Mortality

This was a retrospective observational cohort study using data from the Dutch quality registry National Intensive Care Evaluation evaluating ER to ICU times.

“Prolonged emergency departmentto ICU time (> 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality.”


Metaraminol use during spinal anaesthesia for caesarean section

Phenylephrine has recently displaced Ephedrine as the pressor of choice for spinal induced hypotension during Cesarean Section. However an older agent makes a comeback in this study, although it has remained popular in some countries.

Conclusions:Metaraminol appears superior to ephedrine for the prevention of feto-maternal complications.

Metaraminol is associated with better umbilical arterial pH values than phenylephrine.


Techniques and complications of awake fibre-optic intubation

A survey of Difficult Airway Society members sheds light on awake fibre optic intubation practices.

Most respondents (48%) had performed less than 5 within the last 2 years. Some (10%) had not performed any during this period.

Remifentanil was the most common sedative with local topicalisation and spray-as-you-go local anesthesia.

Complications did not differ between techniques, and included desaturation, multiple attempts or failed intubation.

The low numbers are a cause for concern in this still core technique and expert guidelines are awaited.


Anaesthesia and sedation in breastfeeding women

The Association of Anaesthetists has provided a draft copy open for comment on the topic of breastfeeding and anesthesia/sedation.

In general, the conclusion is that only tiny amounts of most agents are present in breast milk and feeding can be resumed after anesthesia once the mother is awake and lucid. The practice of “pump and dump” is largely unnecessary. However this draft document looks at all commonly used agents in anesthesia and sedation and evidence is in some cases limited, and some agents may pose some degree of risk, like Oxycodone.

Single doses of most analgesics pose little risk but caution is advised with repeated doses.

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Checking mask ventilation before neuromuscular block

The outdated and misguided notion of there being safety in checking mask ventilation before giving the muscle relaxant persists as shown in this Swedish survey.

“The most common reason for checking mask ventilation was “to gather information about the airway,” while the reason for not using was mostly “that muscle relaxation often improves mask ventilation.”

The latter has been shown to be the case. In any event the difficult airway is already lost after Propofol. Airway guidelines need to incorporate this knowledge in guidelines.