Sugammadex vs. Neostigmine

The rapid and complete reversal of neuromuscular block with Sugammadex is undisputed. Other benefits that might justify its cost have been postulated. The current study did not find any difference in nausea and vomiting compared to Neostigmine/Glycopyrrolate. Diplopia, dry mouth and 2 hour sedation scores were improved but no outcome differences apparent at 24 hours. In the real world, rescue Sugammadex after a misjudged attempt at reversal would seem to save a whole lot of trouble!   link

Neuraxial Anesthesia in Placenta Previa

Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A retrospective analysis shows the majority can be done under neuraxial anesthesia with selective conversion to GA. Some variables associated with conversion included high order Cesarean, fibroids, >4 RBC transfusion and high post-op acuity (including ICU admission) but the only independent predictors for GA conversion after adjusting for confounding were surgical duration and >3 Cesareans.   link

Smaller centres may not always be as appropriate in view of the need for ICU and/or arterial embolization.

Multimodal Analgesia Benefits

In the eye of the opioid storm, some data on the use of multimodal analgesia techniques in hip and knee replacement : while not a controlled trial, the data encourage our use of techniques such as nerve blocks, acetaminophen, NSAIDS, COX2 Inhibitors, gabapentinoids, and ketamine. Benefits included lower opioid use, reduced respiratory and gastrointestinal side effects, as well as reduced length of stay   link ASA

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Septic Shock and Steroids -Again!

Just when we thought the ADRENAL trial ( link ) put a damper on steroids, Annane brings us another study.

In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo. Hyperglycemia was more common.

Steroids will likely continue to be used in septic shock, even for their effects other than mortality benefit in the ADRENAL trial   link

 

Ropivacaine vs. Bupivacaine and Bladder Function

Urinary catheters are not without risks and spinal/epidurals are one of the factors that may contribute. In this study, thoracic epidurals (here for renal surgery) effect on bladder function was determined.

Thoracic epidurally administrated bupivacaine 0.125% led to a more pronounced impairment of detrusor activity with a greater increase in post-void residual volume than ropivacaine 0.2%. Based on these results, ropivacaine 0.2% is the preferred drug to achieve early catheter removal or prevent catheterization in other cases.

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Liraglutide for Glucose Control Peri-op

A study in non-cardiac surgery compares Glucose-Insulin-Potassium infusion, Insulin bolus and pre-op Liraglutide (Victoza, Saxenda), a GLP analogue. The first two were equivalent but pre-op Liraglutide stabilized glucose and reduced Insulin requirements. The incidence of pre-op nausea seemed uncomfortably high, and perhaps reflects the GLP’s known side effects which include delayed gastric emptying, both of which should concern Anesthesia.   link

Balanced Crystalloids versus Saline in Critically Ill Adults

Hot on the heels of the pediatric study below ( link ) yet another linking of so-called normal saline to worse outcomes

“Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline”. The % differences were not huge

Nejm

An excellent accompanying editorial, while finding the trial informative,  also cautions the use of composite vs. patient-centred outcomes.

Nejm editorial

And in non-critically ill, another perspective – no mortality benefit but still a renal benefit  link

 

 

Frailty and Ambulatory Surgery

Yet another story on frailty as an independent risk factor after relatively small ambulatory procedures.

“Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities”.

Only local with monitored anesthesia care decreased the odds.

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Hyperchloremia and Pediatric Septic Shock Mortality

Albeit an observational study, and the link to fluid type administration not proven to be causal, a pediatric study associates hyperchloremia >110mmol/l to increased mortality and complicated courses in septic shock. It joins an increasing adult literature on the potential harmful effects of hyperchloremia on renal function, immune function, coagulation and cardiac contractility. ‘Normal’ saline 0.9% may be a poor choice for resuscitation or Critical Care with the posssible exception of brain injury, and increasingly suggestions occur to use Lactated Ringer’s or to replace Chloride with Acetate.   link