1. Working Party of the Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia. 2009 Feb;64(2):199-211 [Article]
Updated guidelines from AAGBI detailing anaphylaxis epidemiology, management and investigation.
Take home message: death or permanent disability from anaphylaxis may be avoidable if the reaction is recognized early and managed optimally & it is the responsibility of the anaesthesia provider to refer patient for appropriate follow-up.
2. Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma. Anesthesiology. 2009 Feb;110(2):351-60 [Article]
Trauma and acute respiratory distress syndrome: weighing the risks and benefits of blood transfusions. Anesthesiology. 2009 Feb;110(2):216-7 [Article]
A retrospective analysis of a large US trauma database analyzing development of ARDS in setting of transfusion of blood products. Author concludes that early transfusion of PRBCs is an independent predictor of ARDS in adult trauma patients.
Take home message: as accompanying editorial suggests- all critical care clinicians should have a compelling physiologic reason to transfuse each individual unit given adverse effects associated with transfusion.
3. Central neuraxial block: defining risk more clearly. Br J Anaesth. 2009 Feb;102(2):151-3
Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009 Feb;102(2):179-90
Analysis of a large audit of central neuraxial block including a census component which enabled estimation of a denominator for calculating risk. Majority of major events occurred in elective surgical procedures involving adult patients. Assessed ‘pessimistically’ the incidence of permanent injury after CNB was 4.2 per 100 000 (‘optimistically’ 2.0/100 000), and of paraplegia/death was 1.8 per 100 000 (‘optimistically’ 0.7/100 000).
Take home message: as stated in accompanying editorial- the study is a triumph for risk management systems and will be invaluable data for anaesthetists providing informed consent.
4. Time to widen our horizons in perioperative medicine: a plea in favor of using patient-centered outcomes. Anesthesiology. 2009 Feb;110(2):209-11 [Article]
Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology. 2009 Feb;110(2):231-8 [Article]
Study which used a US nationwide administrative database to estimate risk of perioperative acute ischaemic stroke and found a surprisingly high incidence: 0.7%/0.2%/0.6% overall for hemicolectomy/THR/lung resection surgery respectively & 1%/0.3%/0.8% for patient >65 yrs having same operations. Predictors included: renal disease, AF, Hx of stroke and cardiac valvular disease.
Accompanying editorial expresses alarm at high stroke incidence while also raising the possibility that the incidence may have been underestimated by the methodology. The editorial suggests anesthesiologists should widen our horizons so that the we provide a service for the entire perioperative period in order to understand and potentially reduce immediate and late complications associated with surgery.
Take home message: perioperative stroke rates may be higher than anaesthetists have realized because the event may occur after our contact with the patient has ended.
5. American Society of Anesthesiologists Task Force on Neuraxial Opioids, Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2009 Feb;110(2):218-30 [Article]
Useful neuraxial opioid management guidelines based on best available evidence that assist in: identification of patients at increased risk of respiratory depression, gives advice re drug selection, makes recommendations about postoperative monitoring of lipophilic vs hydrophilic vs extended release opioids as well as management & treatment of respiratory depression.
Take home message: as stated in one of the taskforce recommendations- single injection neuraxial opioids may be safely used in place of parenteral opioids without altering the risk of respiratory depression or hypoxemia (with adequate monitoring and review).
6. B type natriuretic
peptide--a diagnostic breakthrough in peri-operative cardiac risk
assessment?
Anaesthesia. 2009 Feb;64(2):165-78.
A review of the role of B-type natriuretic peptides in the perioperative period. Author recommends preoperative testing of BtNP levels in patients presenting for major/intermediate risk surgery who have a poor exercise tolerance to assist in cardiac risk stratification and optimizing postoperative care.
Take home message: order BNP if clinically indicated (however you need to know how to interpret the result) & watch this space…
7. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg. 2009 Feb;108(2):422-33. Review.
Comprehensive review of perioperative considerations in right ventricular dysfunction, especially pertaining to cardiac surgery. Review emphasises that RV failure is a strong predictor of perioperative mortality and includes a proposed approach to RV failure.
Take home message: be alert, (not alarmed) when faced with RV dysfunction.
8. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology. 2009 Feb;110(2):284-94.
Sugammadex dose-finding study. Notably, protocol stated that sugammadex was only to be administered after return of second twitch, which was 21.8-32.9 mins post administration of rocuronium! This study only shows sugammadex to be as useful (and likely more expensive) as atropine/glycopyrrolate & neostigmine combination.
Take home question: is sugammadex only useful when partial recovery of neuromuscular function has occurred?
9. Neurocognitive performance in hypertensive patients after spine surgery. Anesthesiology. 2009 Feb;110(2):254-61.
Small post hoc cohort analysis (n=45) which concludes (after very complicated data analysis) that there was a significant relationship between minimum intraoperative MAP (as a fraction of baseline MAP) and decline in cognitive function 1 day and 1 month after surgery in hypertensive patients relative to normotensive patients. Author suggests that even brief periods of decreased blood pressure can be associated with postoperative cognitive impairment.
Take home message: there is some evidence to suggest low MAP intraoperatively may be associated with POCD.
10. Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials. Br J Anaesth. 2009 Feb;102(2):156-67.
Metanalysis of intrathecal morphine use (without local anaesthetic). Take home messages: associated improved analgesia for abdominal surgery>cardiothoracic. The incidence of respiratory depression and pruritis were increased relative to systemic opiods but IT morphine dose was very high in some included studies: 300 mcg-4000 mcg, so it is difficult to interpret the relevance of this finding. Unfortunately, literature did not reveal optimal dose when intrathecal morphine used alone.
Take home message: when used alone IT morphine provides a similar analgesic efficacy as the addition of NSAIDs to a multimodal regime.
11. Disorders of sodium and water balance in hospitalized patients. Can J Anaesth. 2009 Feb;56(2):151-67.
Very detailed review of a complex topic: sodium disorders from a critical care perspective with some emphasis on perioperative implications.
Take home message: sodium disorders are common in hospitalized patients and are associated with increased mortality.
12. Adjuvant analgesics in neuropathic pain. Eur J Anaesthesiol. 2009 Feb;26(2):96-100.
A brief summary of outpatient management of neuropathic pain including drugs that have recently been shown to have some efficacy. Includes NNT and NNH data.
Take home message: hopefully, in the future, drugs will be available that are more efficacious in treating neuropathic pain and are associated with a better side effect profile.