The BMJ provides a great infographic and summary of different types of orofacial pain and headache and their differing treatments, and how to avoid dismissing or misdiagnosing as rhinosinusitis.
A study of severe adverse pediatric anesthesia events across Europe, e.g. respiratory, cardiac, neurological, allergic. Intubation was a marker for increased adverse events, as was emergency surgery, and case volume / pediatric experience of the providers. Children younger than 3 years and those with prematurity, genetic/metabolic/neurological comorbitities, snoring, airway reactivity, with fever or taking medication are at increased risk of severe critical events and should be anesthetized in high-volume pediatric centres.
While not a study on spinal anesthesia, the Mayo Clinic review on lumbar puncture is relevant. They found no cases of spinal hematoma in 100 cases of LP in the presence of dual anti-platelet therapy. The study is small and retrospective, and the need for diagnostic puncture may possibly (pending further studies) be very important and justify the risk; an overwhelmingly strong absolute indication for spinal anesthesia is not so evident, and this small review is unlikely to change anesthesia cautious practice.
A Cochrane review gives the thumbs up to what seems to be the next style of practice in Labor Analgesia – automated mandatory bolus, also known as Programmed Intermittent Epidural Bolus. It is equivalent to a basal infusion with the potential to lower overall local anesthetic consumption and breakthrough pain. It did not appear to increase Cesarean or instrumental delivery.
A Cochrane review finds most of our clinical difficult Airway prediction tools aren’t very good! “Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties”.
They looked at the usual tests like Mallampati, thyromental distance, mouth opening etc.
“Administration of perioperative IV iron reduces the need for blood transfusion, and is associated with a shorter hospital stay, enhanced restoration of iron stores, and a higher mean Hb concentration 4 weeks after surgery“.
Both anemia and blood transfusion are undesirable. One approach here is used in iron deficiency anemia.
Teicoplanin over 16 tines culprit antibiotic in allergic reaction – twice other antibiotics. It seems to be a UK thing in terms of practice.
Test doses don’t serve any real purpose.
Since most anaphylaxis occurs within 5-10 mins a suggestion is to administer before anesthesia induction.
B-Blockers and ACEIs as well as older sicker patients and those with coronary artery disease have more hypotension and do worse.
Obese patients figured highly in mortality cases.
Hypotension is the presenting sign in half. Most severe cases may not show skin rash. Bronchospasm more an initial feature of Succinylcholine, which is also responsible for twice the anaphylaxis rate of non-depolarizing agents. Rocuronium leads the latter pack, followed by Atracurium and Mivacurium. No cases with Vecuronium or Cisatracurium.
There is a potential and debated relationship between Rocuronium allergy and Pholcodine, an opioid cough suppressant especially used in Australia which could sensitize subjects.
Chlorhexidine identified as responsible agent in 9%, often presenting with hypotension that is delayed and missed as diagnosis.
Fluid and epinephrine are the go to treatments not steroids and antihistamines which only play a corollary role. Sugammadex is not at this point an evidence based treatment for Rocuronium allergy. CPR was not started in many cases when it should have been.
Patent Blue dye (used in sentinel node locating in breast surgery) also a significant allergy culprit.
A review of the subject provides some analysis and guidance. Salient points include the epidemic of over diagnosis – most patients don’t remember why they had penicillin or what kind of reaction they had. Some studies have shown as little as 1% true allergy in patients labelled as penicillin allergic. Many receive Penicillin subsequent to an “allergic” reaction. Other studies have shown waning and disappearance of allergies over time. Cross-reactivity to cephalosporins in the population is probably near 1% and not 10% as once reported.
Using alternative antibiotics risks increasing resistance and C Difficile / VRE infections
While there are differences in structure of side chains, as a general guide they recommend proceeding with agents like Cefazolin where s previous reaction was mild and skin only. In major reactions or Stevens-Johnson syndrome it is advised to avoid all B-Lactams including penicillins, cephalosporins, monobactams and carbapenems.
A few studies suggested that using high oxygen concentrations during and after surgery lowered surgical site infection rate. The World Health Organization has recommended FiO2 of 0.8 during and for many hours after surgery to help reduce wound infection. This is totally at odds with the increasing evidence of harm from hyperoxia and many anesthesiologists are reducing oxygen concentrations during surgery (apart from potential difficult airways). The WHO position seems simplistic and reductionist and a critique of their recommendation is found here