Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine: lessons learned from different dosage regimens in two continents.
H.Breivik, U.Bang, J.Jalonen, G.Vigfússon, S.Alahuhta, M.Lagerkranser
Acta Anaesthesiologica Scandinavica 2010; 54(1): 16-41
Methods The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines.
Results Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts’ opinions (weak evidence). The task force reached a consensus on Nordic guidelines.
Conclusions Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.
Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan’s syndrome
E.Langesæter 1 , M.Dragsund 1 , L.a.Rosseland 1
Acta Anaesthesiologica Scandinavica 2010; 54(1): 46-54
Methods All pregnant women with a cardiovascular diagnosis, except hypertension, were included in the registry.
Results A total of 113 pregnancies in 107 women were included. Thirty-two (28.3%) pregnancies were classified into the high-risk category. Of 103 deliveries, caesarean sections were performed in 59 (52.2%) cases, with regional anaesthesia in 51 patients (18 emergencies), general anaesthesia in eight patients (five emergencies), and a planned vaginal delivery in 44 patients. There was no mortality among the mothers or the babies during the hospital stay or 6 months postpartum. Pre-operative cardiovascular stability during the caesarean section was maintained by volume and phenylephrine infusion guided by invasive monitoring of haemodynamic variables.
Conclusion Our study suggests that pregnant women with cardiac disease may safely deliver the baby by a caesarean section under regional anaesthesia. According to our findings, haemodynamic stability can be obtained by titrated regional anaesthesia, intravenous (i.v.) volume, phenylephrine infusion, and small repeated doses of i.v. oxytocin guided by invasive monitoring.
Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan
Chester C. Buckenmaier III, Christine Rupprecht, Geselle McKnight, Brian McMillan, Ronald L. White, Rollin M. Gallagher, Rosemary Polomano.
Pain Medicine 2009; 10(8): 1487-96
Results Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = −0.58 and r = −0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05). Average percent pain relief achieved was 45.2% ± 26.6% during transport and 64.5% ± 23.5% while at LRMC (P < 0.001). Participants with CPNB catheters placed at LRMC reported significantly less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs.
Conclusions Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes.
The Effects of Crystalloid and Colloid Preload on Cardiac Output in the Parturient Undergoing Planned Cesarean Delivery Under Spinal Anesthesia: A Randomized Trial
Perumal Tamilselvan, Roshan Fernando, Johanna Bray, Manisha Sodhi, Malachy Columb.
Anesthesia & Analgesia 2009; 109(6): 1916-21
Background We hypothesized that colloid solutions, compared with crystalloid, would produce the largest increase in CO and have the lowest incidence of hypotension.
Methods Sixty healthy term women scheduled for planned cesarean delivery under spinal anesthesia were recruited for this randomized, double-blind study. Patients were randomized to receive 1 of 3 fluid preload regimens given over 15 min: 1.5 L crystalloid (Hartman’s solution), 0.5 L of 6% w/v hydroxyethyl starch (HES) solution (HES 0.5), or 1 L of 6% w/v HES solution (HES 1.0). The primary outcome, CO, was compared among groups. The incidence of hypotension (defined as a 20% reduction in SBP from the baseline), ephedrine use, and umbilical cord blood gases were also compared.
Results Patient characteristics, heart rate, SBP, and cord gases were similar among groups. Although CO and FTc increased after preload in all groups (P < 0.005), this was only maintained with HES 1.0 after spinal anesthesia (P < 0.005). There were no differences among groups in the incidence of hypotension (70% vs 35% vs 65% for Hartman’s solution, HES 0.5, and HES 1.0, respectively; P = 0.069) or mean ephedrine dose (10.4 vs 5.7 vs 9.7 mg; P = 0.26).
Conclusion Despite CO and FTc increases after fluid preload, particularly with HES 1.0 L, hypotension still occurred. The data suggest that CO increases after these preload regimens cannot compensate for reductions in arterial blood pressure after spinal anesthesia.
Transcatheter aortic valve insertion: anaesthetic implications of emerging new technology
A. A. Klein1,*, S. T. Webb1, S. Tsui2, C. Sudarshan2, L. Shapiro3 and C. Densem3
BJA 2009; 103(6): 792-9
Transcatheter aortic valve insertion is a new development that potentially offers a number of advantages to patients and healthcare providers. These include the avoidance of sternotomy and cardiopulmonary bypass, and much faster discharge from hospital and return to functional status. The procedure itself however is quite complex, and presents significant demands in planning and implementation to the multidisciplinary team. Anaesthetic input is essential, and patient care in the perioperative period can be challenging. Early results have shown a significant mortality and morbidity rate, but the majority of procedures to date have been carried out in elderly patients with multiple comorbidities, making comparison with surgical aortic valve replacement inappropriate. Long-term outcomes are not yet known.
A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery
Sherif Farouk1, 3 and Ansam Aly2
Journal of Anesthesia 2009; 23(4): 508-12
Purpose This study was designed to compare the analgesic effects of intra-articular magnesium and morphine, with bupivacaine, when used separately and in combination.
Results Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups.
Conclusion Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.
Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery
T. N. Weingarten1, F. X. Whalen1, D. O. Warner1, O. Gajic2, G. J. Schears1, M. R. Snyder3, D. R. Schroeder4 and J. Sprung1,*
BJA 2009; aop: 10.1093/bja/aep319
Background ‘Open lung’ ventilation is commonly used in patients with acute lung injury and has been shown to improve intraoperative oxygenation in obese patients undergoing laparoscopic surgery. The feasibility of an ‘open lung’ ventilatory strategy in elderly patients under general anaesthesia has not previously been assessed.
Results The RM group tolerated open lung ventilation without significant haemodynamic instability. Intraoperative PaO2 improved in the RM group (P<0.01) and deteriorated in controls (P=0.01), but postoperative PaO2 was similar in both groups. The RM group had improved breathing mechanics as evidenced by increased dynamic compliance (36%) and decreased airway resistance (21%). Both IL-6 and IL-8 significantly increased after surgery, but the magnitude of increase did not differ between the groups.
Conclusions A lung recruitment strategy in elderly patients is well tolerated and improves intraoperative oxygenation and lung mechanics during laparotomy.
The GlideScope Ranger® video laryngoscope can be useful in airway management of entrapped patients: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
A.R.Nakstad 1,2 , M.Sandberg 1
Acta Anaesthesiologica Scandinavica 2009; 53(10): 1257-61
Methods Eight anaesthesiologists from a Helicopter Emergency Medical Service intubated the trachea of a Laerdal SimMan® manikin using the studied laryngoscopes in two scenarios: (A) unrestricted access to the manikin in an ambulance and (B) no access from the head end, simulating an entrapped patient. The time used to secure the airway and the scored level of difficulty were the main variables.
Results In scenario A, all anaesthesiologists managed to secure the airway using both techniques within the 60-s time limit. In scenario B, all secured the airway when using the video laryngoscope, while 50% succeeded with endotracheal intubation using the Macintosh laryngoscope.
Conclusion This study suggests that the Glidescope Ranger® may be merited in situations requiring endotracheal intubation by an experienced intubator in patient entrapment. Further studies are required to clarify whether performance in patients mimics that in a manikin.
A Comparison of Postoperative Throat and Neck Complaints after the Use of the i-gel® and the La Premiere® Disposable Laryngeal Mask: A Double-Blinded, Randomized, Controlled Trial
Christiaan Keijzer, Dirk R.Buitelaar, Katina M.Efthymiou, Michael Šrámek, Julia Ten Cate, May Ronday, Tino Stoppa, Johannes M.Huitink, Peter F.Schutte.
Anesthesia & Analgesia 2009; 109(4): 1092-5
Results One hundred nine patients had an i-gel and 103 had a La Premiere supraglottic device inserted. The incidence of sore throat was significantly lower with the i-gel than with LM at 1 (6 vs 32), 24 (7 vs 48), and 48 h (5 vs 25). Similar results were seen for dysphagia. The incidence of neck pain was also lower for the i-gel at 24 (1 vs 7) and 48 h (1 vs 7).
Conclusion In this randomized study, the i-gel supraglottic device resulted in a lower incidence of throat and neck complaints than the La Premiere LM airway.
