Anesthesia Management

Spinal Anesthesia Failure

This retrospective study analyzed the factors associated with spinal anesthesia failure in patients undergoing elective total hip or knee arthroplasty.

The factors associated with increased odds of spinal failure included younger age, lower BMI, hip arthroplasty vs. knee arthroplasty, needle insertion at L4-5 and L5-S1 vs. L2-3, 22-gauge needle size vs. 25-gauge needle, and hyperbaric bupivacaine vs. isobaric bupivacaine.

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Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty

This large national cohort “identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.”

Benzodiazepines and gabapentinoids were associated with higher odds of delirium, whereas lower risk of delirium was associated with neuraxial vs. general anesthesia, use of NSAIDs and COX2 Inhibitors, and high vs low opioid use specifically in the over 65 year olds.

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block

Hemi-diaphragmatic paralysis from Phrenic Nerve Block is a frequent accompaniment to Interscalene Brachial Plexus Block that may be detrimental to those with compromised respiratory function.

This randomized trial compared the more selective targeting of the nerves using the more novel Superior Trunk Block employing ultrasound.

Conclusions: “Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.”

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In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis

This latest malpractice analysis still leaves concern for the outcomes in difficult tracheal intubation, showing outcomes still remain poor. Death is still a not uncommon occurrence.

The authors summarize: “Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.”

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Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

The latest newcomer to regional anesthesia in breast cancer surgery is the PEC-2 Block.

This review and meta-analysis shows essentially an equivalence to Paravertebral Block.

“Petoralis-II blocks were noninferior to paravertebral blocks in reducing pain intensity and morphine consumption for the first 24 h after surgery and both were superior to systemic analgesia alone”.

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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