Prehabilitation

Yes it’s a word. Although the evidence is still just coming in, enhanced recovery after surgery may begin preoperatively for major surgery. It’s a “combination of aerobic training, resistance training and inspiratory muscle training to promote positive adaptations in cardiorespiratory fitness, muscular strength and endurance and respiratory muscle function, respectively”.

Anaesthesia guidelines

Cricothyrotomy (FONA)

The wire guided Seldinger technique (that was easy enough for an anesthesiologist to understand!) is no longer recommended. If the membrane is palpable, one full thickness transverse incision into the trachea; if not palpable an initial vertical incision so you don’t end up above the larynx.

A FONA (front of neck airway) Difficult Airway Society video that we all hope never to re-enact!

Front of Neck Airway

 

Top medical news this week

 

BRCA mutation doesn’t affect young onset breast cancer survival link

Consider evidence before prescribing gabapentinoids outside approved indications link

Genetic obesity predisposition has as much or more to gain from healthy diet link

Curb opioids like Codeine in cough medications. Only for over 18 year old link

Infants must sleep on back, not in your bed, no soft bedding or objects. Not everyone knows this still link

Peripheral Nerve Injury in Anesthesia

Attention to detail in positioning and knowing the risk factors like diabetes, thyroid disease, alcohol, “Established peripheral neuropathy, pre-existing (but subclinical) peripheral neuropathy, profound hypothermia, hypovolaemia, hypotension, hypoxaemia, electrolyte disorders, malnutrition, small or large body mass index (BMI), tobacco use and anatomical variants (such as the presence of cervical ribs) may increase the susceptibility of peripheral nerves to peri-operative injury”.

The complexity of predisposing conditions, surgical injury and tourniquet use are explored in the ASRA practice advisory  ASRA advisory

Anesthesiology (Here) publishes guidelines Jan 2018 for the prevention of peripheral nerve injury. Avoid pressure on nerves with padding if needed, avoid excessive flexion or extension of any joint, and none of those pesky  shoulder brace thingies. And I’ve saved you a lot of reading!

Anaesthesia article (free)

Respiratory Risk Assessment

An excellent review of the pre-operative  risk factors for pulmonary complications or respiratory failure post-op.

Age, COPD, recent respiratory infection or pre-op symptoms, ASA Class >II, heart failure. Albumin < 3.5g/dl, smoking, alcohol, functional dependence, sepsis, hepatic and renal disease, anemia, recent weight loss >10%, cancer, impaired sensorium, low oxygen saturation, emergency surgery, thoracic/upper abdominal/ major vascular surgery, duration >2 hours.
Controlled asthma and obesity not major risks, OSA uncertain.

Clinics article

Spinal Cord Injury and Neuraxial Block

Vigilance over complacency in this area. Rare but catastrophic potential of spinal and epidural anesthesia. An article and the NAP3 data. Themes include greater risk in elderly, and epidurals and CSE vs spinal. Obstetric and pediatric risk appears lower. Some preventable incidents like wrong route delivery and hypotension

“Assessed ‘pessimistically’ the incidence of permanent injury after CNB was 4.2 per 100 000, and of paraplegia/death was 1.8 per 100 000. ‘Optimistically’ the incidence of permanent injury was 2.0 per 100 000 and of paraplegia/death 0.7 per 100 000. The incidence of complications of epidural and CSE were at least twice those of spinals and caudals.”

Anaesthesia article

NAP3 findings