1 Perioperative use of beta-adrenergic antagonists and anemia: known knowns, known unknowns, unknown unknowns; and Unknown Knowns. Weiskopf RB. Anesthesiology. 2010 Jan;112(1):12-5. [Editorial]
Acute surgical anemia influences the cardioprotective effects of beta-blockade: a single-center, propensity-matched cohort study. Beattie WS et al. Anesthesiology. 2010 Jan;112(1):25-33. [Article]
The primary outcome of this retrospective analysis of predominantly low-risk non-cardiac surgery patients (n=4,377) was major cardiac event (a composite endpoint that included myocardial infarction, nonfatal cardiac arrest, and in-hospital mortality). The investigators matched 827 of the 1,153 patients who were administered beta-blockers within the first 24 hours of surgery using propensity scores for measured confounders and found an increased incidence of the composite cardiac endpoint. Major adverse cardiac events occurred in 6.5% of beta-blocked patients and in 3% of beta-blocker naïve patients (RR 2.34, p=0.0009). The major differences between the two groups of patients seemed to occur after the Hb had dropped by 35% of the baseline level. A potential explanation of this observation is that beta-blockade attenuates the acute cardiovascular response to surgical anaemia. The statistics of this study are sophisticated, however some obvious limitations include the fact that the study was underpowered to show a cardioprotective effect of beta blockers, patients taking beta-blockers had a higher incidence of high-risk surgery, the study did not prospectively measure troponin in all patients and the effect of unknown or unmeasured confounders cannot be excluded. Prospective studies would be required to validate these findings, however it is doubtful that these will ever be conducted.
Take home message: This retrospective, observational study suggests the transfusion trigger should possibly be higher in elective non-cardiac surgical patients taking beta-blockers.
See also: March 09 Journal Watch (2); May 09 Journal Watch (12)
2 Practice guidelines often fail to keep pace with the rapid evolution of medicine: a call for clinicians to remain vigilant and revisit their own practice patterns. Editorial: Fleischmann KH. Reg Anesth Pain Med. 2010 Jan-Feb;35(1):4-7.
Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Horlocker TT et al. Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101.
Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Horlocker TT et al; American College of Chest Physicians. Reg Anesth Pain Med. 2010 Jan-Feb;35(1):102-5.
The 2010 ASRA guidelines once again focus on patients receiving neuraxial techniques however this update also provides the current evidence base relevant to thromboprophylaxis in the parturient and some guidance for peripheral techniques.
Guidelines include specific important recommendations:
“in patients who have received fibrinolytic and thrombolytic drugs, we recommend against performance of spinal or epidural anaesthetics….”
“in patients receiving prophylaxis with subcutaneous UFH and dosing regimens of 5000 IU twice daily, there is no contraindication to the use of neuraxial techniques….the safety of neuraxial blockade in patients receiving doses greater than 10,000 U of UFH daily or more than twice-daily dosing of UFH has not been established….”
“patients on preoperative LMWH thromboprophylaxis can be assumed to have altered coagulation…we recommend that needle placement should occur at least 10-12 hrs after the LMWH dose….in patients receiving higher dose os LMWH (i.e enoxaparin 1 mg/kg every 12 hrs), datelparin 120 U/kg every 12 hrs)….we recommend delay of at least 24 hrs….”
“patients with postoperative LMWH thromboprophylaxis…..timing of first postoperative dose…twice-daily dosing…no earlier than 24 hrs postoperatively…single daily dosing…6-8 hrs postoperatively….”
“on the basis of labeling and surgical reviews, the suggested time tinterval between discontiuation of thienopyridine therapy and neuraxial block is 14 days for ticlopidine and 7 days for clopidogrel…..”
“in patients receiving thrombin inhibitors (desirudin, lepirudin, bivalirudin and argatroban), we recommend against the performance of neuraxial techniques….”
“the actual risk of spinal haematoma with fondaparinux is unkown….performance of neuraxial techniques should occur under condition used in clinical trials….”
With regard to dabigatran and rivoxaban: “information regarding the specifics of block performance and the prolonged half-life warrants a cautious approach…”
For the the anticoagulated parturient: “we suggest ASRA guidelines be applied to paturients…”
For anaesthetic management of patient undergoing plexus or peripheral block: “for patients undergoing deep plexus or peripheral block (lumbar sympathetic, lumbar plexus, and paravertebral), we recommend that recommendations regarding neuraxial techniques be similarly applied…”
Of interest, recommendations for regional anaesthetic management of the patient on warfarin includes detailed recommendation regarding that in the first 1-3 days after discontinuation of warfarin therapy, the coagulation status (reflected primarily by factor II and X levels) may not be adequate for haemostasis despite an apparent adequate decrease in the INR. . Emphasis is also placed on combination of antihaemostatic drugs (including NSAIDs) leading to a higher potential for bleeding than single drugs in isolation and hence the need for daily review of the medical record. Other interesting points include: Prothrombin X for warfarinised patients is not mentioned (? not available in the US), practioners need to consider that the duration of thromboprophylaxis can be from 10-25 days postoperatively and there is no evidence base provided for options for bridging therapy in procedures which necessitate interruption of thienopyridine antiplatelet therapy (likely insufficient evidence). The accompanying editorial suggests, especially in reference to the appearance of new drugs, the best guide to determine practice recommendations may be our knowledge of the pharmacokinetics and pharmacodynamics of the drug. The latter is especially important for decisions such as the timing of administration of anticoagulant at a particular dose in relation to placement of an epidural catheter. Finally, in a large case series of spinal haematoma (Vandermeulen et al, Anes Anal. 1994) 13 % of patients had no identifiable risk factor. As such, vigilance and monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention. Protocols must be in place for urgent MRI and haematoma evacuation if there is a change in neurological status. Of note this case series has also revealed that the presenting symptom of spinal haematoma is most often increased motor block (83%) rather than back pain.
Take home message: Fleischmann et al. “Guidelines have been a tremendous advance in bringing care across disparate practice environments toward a reasonable and similar standard, but they should not be viewed as either fixed and immutable recommendations or an absolute standard of care.”
See also: Feb 09 Journal Watch (3);
3 Scandinavian guidelines for neuraxial block and disturbed haemostasis: replacing wishful thinking with evidence based caution. Editorial: Moen V. Acta Anaesthesiol Scand. 2010 Jan;54(1):6-8.
Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Breivik H et al. Acta Anaesthesiol Scand. 2010 Jan;54(1):16-41.
These guidelines are the consensus recommendations of experts from the five Nordic countries (Norway, Sweden, Finland, Denmark, Iceland) for safe clinical practice of neuraxial blocks. The authors state it is an evidence-based review of the risk and benefits of central neuraxial blockade (CNB), incidence of major complications (spinal haematoma (SH) and epidural abscess) and provides recommendations to minimize the risks of intraspinal bleeding. The authors provide guidelines for the timing of initiation of CNB in relation to the dosing of anti-haemostatic agents and timing of subsequent anti-haemostatic drugs post CNB and when catheter manipulation/removal is planned. Much emphasis is placed on well-known thromboprophylaxis drugs that need special attention before CNB: heparins/Xa-inhibitors (UFH, datelparin,enoxaparin), vitamin K-antagonists and thrombolytic drugs. The interval between CNB and drug for therapeutic dose LMWH regimes is much shorter in the Nordic guidelines compared to ASRA-6 vs 24 hours respectively. Alarmingly, an interval of 6-24 hrs is thought to be safe between administration of parenteral thrombolysis and neuraxial block whereas neuraxial block is contraindicated in the setting of recent thrombolysis in the ASRA guidelines. Plasma expanders and platelet inhibitors are covered as well as recently released drugs: fondaparinux (Xa+anti-thrombin), rivoxaban (Xa), apixaban (Xa), dabigatran (thrombin inhibitor) and prasugrel (platelet inhibitor). Notably, the recommendations for cessation of clopidogrel/ticlopidine of 5 days contrast significantly with the 2010 ASRA guidelines 7/14 days respectively. Likewise, the Nordic guidelines provide low-level evidence based recommendations for fondaparinux and rivaroxaban that are different or lacking from the ASRA guidelines. The guidelines recommend a platelet count in patients treated with UFH for more than 5 days prior to initiation of CNB, a variable drug free interval for all NSAIDs (not low dose aspirin for secondary prevention), and monitoring of post-operative renal function in elderly patients with epidurals. In contrast to the ASRA guidelines, the Nordic guidelines also include patient and procedure factors in addition to antihaemostatic drugs. An outline is provided of haematological disorders, spinal deformities and vascular malformations potentially associated with an increased bleeding tendency as well as the potential impact of renal and hepatic failure. Low-level evidence is provided regarding the number of normally functioning platelets acceptable for CNB. Once again, the guidelines differ significantly to the recently released ASRA guidelines. The Nordic guidelines seem much more pro-neuraxial block and are willing to tolerate relatively high INRs and low platelet counts if the clinician feels that there is a perceived morbidity/mortality benefit. The importance of post-operative monitoring of CNB is also emphasized. The accompanying editorial notes the lower incidence of complications in epidural block for obstetrics compared to perioperative epidurals.
Take home message: The ‘evidence-based’ Nordic guidelines for neuraxial blocks in disturbed haemostasis are significantly less conservative than the recently published updated ‘evidence-based’ ASRA guidelines proving the consensus derived from the evidence can be more closely related to clinician perspective of risk-benefit analysis.
4 Incidence of residual neuromuscular blockade in a post-anaesthetic care unit. Yip PC et al. Anaesth Intensive Care. 2010 Jan;38(1):91-5.
This prospective observational study assessed the incidence of residual neuromuscular blockade (RNMB) in a PACU of a tertiary hospital in New Zealand. The subjects were a sample of convenience- 102 non-consecutive patients undergoing relaxant general anaesthesia and the procedural anaesthetists were unaware of their patients’ inclusion in the study. On arrival to the PACU, the train of four (TOF) was assessed using electromyography and repeated every five minutes until the TOF exceeded 0.9. RNMB was defined as <0.9. Eight patients were excluded due to TOF monitoring difficulties. Atracurium was administered to the majority of patients, with the others receiving vecuronium or rocuronium however despite use of intermediate acting agents, RNMB was observed in 31%. The average TOFR was 0.62. The mean interval between the last dose of relaxant and arrival in the PACU for patients with RNMB was 81 minutes. Secondary outcome analysis revealed a greater proportion of patients with RNMB required airway support. The rate of administration of reversal was 61% and the incidence of RNMB was not significantly lower in patients who had received neostigmine.
The degree of discomfort experienced by the patients having awake TOF monitoring was not reported. Limitations of this study are the small sample size and it is difficult to believe that all anaesthetists would have remained unaware of the conduct of the study, especially when anaesthetists were personally contacted if their patient had a high degree of RNMB. However, the findings are relevant to many comparable centers considering the lack of routine objective neuromuscular monitoring during relaxant general anaesthesia and the fact that many anaesthetists do not routinely use reversal agents if 1 hour has elapsed after the last dose of relaxant.
Take home message: RNMB is common and may predispose to postoperative complications, emphasizing the need for appropriate attention to objective/quantitative monitoring of NMB and reversal as necessary.
See also: June 09 Journal Watch (11); March 09 Journal Watch (6)
5 Neostigmine: how much is necessary for patients who receive a nondepolarizing neuromuscular blocking agent? [Editorial] Lien CA. Anesthesiology. 2010 Jan;112(1):16-8.
Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine. Fuchs-Buder T et al. Anesthesiology. 2010 Jan;112(1):34-40.
The purpose of this RCT (n=120) was to investigate the dose-effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4-0.6, in patients undergoing intravenous/N20 anaesthesia. The patients received placebo or 10, 20, 30 mcg/kg of neostigmine at a TOF of either 0.4 (n=60) or 0.6 (n=60) assessed by acceleromyography (quantitative nerve stimulation). The probability of successful reversal after 20 mcg/kg of neostigmine was 100% when a TOF ratio of 0.9 was the target. When a TOF ratio of either 0.4 or 0.6, time to 0.9 and 1.0 TOF ratio was significantly shorter with any dose of neostigmine than without. The highest dose of neostigmine tested resulted in reversal from TOF 0.4-0.9 in 5 mins whereas lower doses achieved reversal in 10 mins. Importantly, no patient developed weakness after administration of anticholinesterase. It is important to not that shallow degrees of block (TOF 0.4-0.6) cannot be detected reliably by using a simple peripheral nerve stimulator and visual/tactile assessment of TOF fade by the anaesthetist. The author of the accompanying editorial suggests that all patients who receive an NMBA should receive an anticholinesterase because, even when the TOFR has recovered to unity, the majority of acetylcholine receptors may still be occupied by NMBA. She suggests use of doses of neostigmine <30 mcg/kg when no fade is appreciable in the TOFR requires that quantitative monitors be available to document the depth of block being antagonized as well as the time to complete recovery of neuromuscular function.
Take home message: Compared to doses of neostigmine (40-70 mcg/kg) required to antagonise moderate NMB (TOF 1-3), in patients undergoing intravenous/N20 anaesthesia with a shallow residual block from atracurium (TOF 0.4-0.6), a small dose of neostigmine (20 mcg/kg) produces successful reversal within 10 mins.
For related reading this month:
Staals LM et al. Reduced clearance of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth. 2010 Jan;104(1):31-9.
Duvaldestin P et al. A randomized, dose-response study of sugammadex given for the reversal of deep rocuronium- or vecuronium-induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg. 2010 Jan;110(1):74-82.
Khuenl-Brady KS et al. Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg. 2010 Jan;110(1):64-73
6 Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Buvanendran A et al. Anesth Analg. 2010 Jan;110(1):199-20.
This RCT (n=240) compared a two-week course of pregabalin commencing immediately prior to surgery with placebo administration in patients having TKR under combined spinal-epidural anaesthesia. The incidence of neuropathic pain was less frequent in the pregabalin group (0%) compared with the placebo group (8.7% and 5.2%, at 3 & 6 months respectively; p=0.001 and p=0.014). In addition, patients receiving pregabalin also consumed less oral and epidural opioids and had an improved postoperative active and passive range of motion but had a statistically significant higher rate of sedation & confusion on the day of surgery and postoperative day 1. Limitations of this study include patients who were lost to follow-up (n=12) and patients who did not receive study medication (n=11). The authors also suggest lower pregabalin doses should be considered in future studies.
Take home message: This study suggests pregabalin may play a role in a strategy to reduce chronic pain after TKR at the expense of a transiently higher risk of postoperative sedation & confusion.
For related reading this month:
White PF et al. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010 Jan;112(1):220-5.
7 Pressures available for transtracheal jet ventilation from anesthesia machines and wall-mounted oxygen flowmeters. Fassl J et al. Anesth Analg. 2010 Jan;110(1):94-100
The authors of this study measured driving pressures in a jet ventilation test system with a 14G IV catheter in 4 types of wall mounted oxygen flowmeters (Puritan, Allied Health, Precision, Datex-Ohmeda) and the auxiliary oxygen flowmeters as well as the oxygen flush valves on 4 types of anaesthesia machines (Draeger narkomed 2B & 4, Datex-Ohmeda Excel and Modulus). Relying on the premise that that the working pressure needed to be at least 15 psi to drive sufficient oxygen through a 14G IV catheter, the authors determined which set-ups would be adequate to enable jet ventilation. Sufficient working pressures were delivered by all types of wall-mounted oxygen flowmeters opened past their ‘rated’ flow (16-41 psi), the auxiliary oxygen flowmeter on the Datex-Ohmeda machines (27-36 psi) and the oxygen flush valves on the Draeger machines (14-17 psi). Insufficent working pressures were found on the auxiliary oxygen flowmeters on the Draeger machines (2-4 psi) as well as the Datex-Ohmeda flush valves (7-9 psi).
Take home message: Oxygen sources, other than dedicated jet ventilator connectors to high pressure pipeline oxygen (Sanders, Manujet), may supply adequate working pressure, but each type of oxygen source needs testing to ensure that it supplies adequate working pressure.
See also: Dec 09 Journal Watch (3); June 09 Journal Watch (1&2)
Other articles of particular interest this month:
AIRWAY
Xue FS et al. Airway topical anaesthesia and awake tracheal intubation using the Airtraq laryngoscope alone. Acta Anaesthesiol Scand. 2010 Jan;54(1):120
Bathory I et al. Evaluation of the Video Intubation Unit in morbid obese patients. Acta Anaesthesiol Scand. 2010 Jan;54(1):55-8.
Minonishi T et al. Tracheal intubation with the AirwayScope videolaryngoscope using straight vs curved reinforced tubes. Can J Anaesth. 2010 Jan;57(1):92-3.
Jones PM et al. Comparison of a single-use GlideScope Cobalt videolaryngoscope with a conventional GlideScope for orotracheal intubation. Can J Anaesth. 2010 Jan;57(1):18-23.
Asai T. Pentax-AWS videolaryngoscope for awake nasal intubation in patients with unstable necks. Br J Anaesth. 2010 Jan;104(1):108-11
Uslu B et al. McGrath videolaryngoscope for awake tracheal intubation in a patient with severe ankylosing spondylitis. Br J Anaesth. 2010 Jan;104(1):118-9.
Sanuki T et al. The Parker Flex-Tip tube for nasotracheal intubation: the influence on nasal mucosal trauma. Anaesthesia. 2010 Jan 1;65(1):8-11.
Moharari RS et al. The GlideScope facilitates nasogastric tube insertion: a randomized clinical trial. Anesth Analg. 2010 Jan;110(1):115-8.
Greenland KB. Airway assessment based on a three column model of direct laryngoscopy. Anaesth Intensive Care. 2010 Jan;38(1):14-9. Review.
Scott DA et al. Development of an 'Equipment to manage a difficult airway during anaesthesia' professional document using a new evidence-based approach. Anaesth Intensive Care. 2010 Jan;38(1):11-2.
Zugai BM et al. Practice patterns for predicted difficult airway management and access to airway equipment by anaesthetists in Queensland, Australia. Anaesth Intensive Care. 2010 Jan;38(1):27-32
Sharma DJ et al. Comparison of the Pentax Airway Scope and McGrath Videolaryngoscope with the Macintosh laryngoscope in tracheal intubation by anaesthetists unfamiliar with videolaryngoscopes: a manikin study. Anaesth Intensive Care. 2010 Jan;38(1):39-42.
Siu LW et al. Patient- and operator-related factors associated with successful Glidescope intubations: a prospective observational study in 742 patients. Anaesth Intensive Care. 2010 Jan;38(1):70-5
Serocki G et al. Management of the predicted difficult airway: a comparison of conventional blade laryngoscopy with video-assisted blade laryngoscopy and the GlideScope. Eur J Anaesthesiol. 2010 Jan;27(1):24-30.
CARDIAC
Karkouti K et al. The risk-benefit profile of aprotinin versus tranexamic acid in cardiac surgery. Anesth Analg. 2010 Jan;110(1):21-9.
Editorial: Despotis GJ et al. Plasma exchange for heparin-induced thrombocytopenia: is there enough evidence? Anesth Analg. 2010 Jan;110(1):7-10.
Welsby IJ et al. Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia. Anesth Analg. 2010 Jan;110(1):30-5.
CRITICAL CARE
Hunter JD et al. Sepsis and the heart. Br J Anaesth. 2010 Jan;104(1):3-11.
Samarütel J. Evidence-based medicine for lung-protective ventilation: the emperors new clothes for doubtful recommendations? Acta Anaesthesiol Scand. 2010 Jan;54(1):42-5
GENERAL TOPICS
Editorial: Nunnally ME et al. New insights about an old foe. Anesthesiology. 2010 Jan;112(1):10-1.
Turan A et al. Effects of dexmedetomidine and propofol on lower esophageal sphincter and gastroesophageal pressure gradient in healthy volunteers. Anesthesiology. 2010 Jan;112(1):19-24.
Mantz J et al. Case scenario: postoperative delirium in elderly surgical patients. Anesthesiology. 2010 Jan;112(1):189-95.
Sanders RD et al. Neuroinflammation and postoperative cognitive dysfunction: can anaesthesia be therapeutic? Eur J Anaesthesiol. 2010 Jan;27(1):3-5.
Nickalls RW et al. Awareness and anaesthesia: think dose, think data. Br J Anaesth. 2010 Jan;104(1):1-2.
Fioratou E et al. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2010 Jan;65(1):61-9.
Editorial: Yentis S. Of humans, factors, failings and fixations. Anaesthesia. 2010 Jan;65(1):1-3
Candiotti KA et al; MAC Study Group. Monitored anesthesia care with dexmedetomidine: a prospective, randomized, double-blind, multicenter trial. Anesth Analg. 2010 Jan;110(1):47-56.
Chu KS et al. The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation. Eur J Anaesthesiol. 2010 Jan;27(1):36-40.
Shi Y et al. Surgery as a teachable moment for smoking cessation. Anesthesiology. 2010 Jan;112(1):102-7.
Christensen RE et al. Anaesthetic management and outcomes in patients with surgically corrected D-transposition of the great arteries undergoing non-cardiac surgery. Br J Anaesth. 2010 Jan;104(1):12-5.
Zufferey PJ et al.; tranexamic acid in hip-fracture surgery (THIF) study. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth. 2010 Jan;104(1):23-30.
NEUROANAESTHESIA
Hindman BJ et al; IHAST Investigators. No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial. Anesthesiology. 2010 Jan;112(1):86-101.
Mantz J et al. Recent advances in pharmacologic neuroprotection. Eur J Anaesthesiol. 2010 Jan;27(1):6-10.
OBSTETRICS
Onuki E et al. Gestation-related reduction in lumbar cerebrospinal fluid volume and dural sac surface area. Anesth Analg. 2010 Jan;110(1):148-53. -
Banerjee A et al. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth. 2010 Jan;57(1):24-3
Langesaeter E et al. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand. 2010 Jan;54(1):46-54.
PAIN
Dahan A et al. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology. 2010 Jan;112(1):226-38.
REGIONAL ANAESTHESIA
Randhawa K et al. Sonographic assessment of the conventional 'blind' ilioinguinal block. Can J Anaesth. 2010 Jan;57(1):94-5.
Editorial: Chin KJ et al. Evaluating outcomes in ultrasound-guided regional anesthesia. Can J Anaesth. 2010 Jan;57(1):1-8.
Editorial: Horlocker TT. Neuraxial blockade in patients with spinal stenosis: between a rock and a hard place. Anesth Analg. 2010 Jan;110(1):13-5
Davidson EM et al. Magnetic resonance imaging findings after uneventful continuous infusion neuraxial analgesia: a prospective study to determine whether epidural infusion produces pathologic magnetic resonance imaging findings. Anesth Analg. 2010 Jan;110(1):233-7.
Editorial: Benhamou D et al. Safety during regional anesthesia: what do we know and how can we improve our practice? Reg Anesth Pain Med. 2010 Jan-Feb;35(1):1-3.
Benzon HT et al. Clopidogrel and neuraxial block: the role of the PFA II and P2Y12 assays. Reg Anesth Pain Med. 2010 Jan-Feb;35(1):115.
TRAUMA ANAESTHESIA
Durga P et al. Development and validation of predictors of respiratory insufficiency and mortality scores: simple bedside additive scores for prediction of ventilation and in-hospital mortality in acute cervical spine injury. Anesth Analg. 2010 Jan;110(1):134-40
LITERATURE REVIEW (from non-anaesthesia journals in past 12 months)
Jabre P et al; KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300.
Written by Maryanne Balkin, Februrary 2010
Feedback welcome: M.Balkin@alfred.org.au