June 2011 Journal Watch
1. Supplementing oxygen through an airway
exchange catheter: efficacy, complications, and
recommendations. Duggan LV et al. Brief
review: Can J Anaesth. 2011 Jun;58(6):560-8.
Airway exchange catheters (AEC) are found commonly on Difficult
Airway Trolleys and strongly promoted at trade displays for use as
a conduit for ETT placement. The main indications for use of
an AEC is an aid to ETT exchange in an anaesthetized patient or to
act as a conduit for re-intubation in an awake spontaneously
breathing patient during a trial of extubation. They are
available in 8-19 Fr diameters and their �claim to fame� is that
they enable administration via a central lumen, prior to securing
the airway. Oxygen can be administered through an AEC using
either high-pressure or jet ventilation (usually 10-50 psi) or
low-pressure variable flow oxygen (usually 1-10L/min). It is
somewhat surprising that a recent literature review in the CJA
found that there has never been a study published comparing either
oxygen insufflation or jet-ventilation through an AEC to any
standard forms of oxygen therapy. More importantly, the
literature review was prompted by the Chief Coroner of Ontario
after a recent death of a young healthy patient who received oxygen
insufflation only after maxillo-facial surgery via an AEC &
sustained a fatal tension pneumothorax. The authors were able
to find one case series using AEC jet ventilation (n=45) that
reported an 11% incidence of pulmonary barotrauma. Thirteen
other cases reports documented jet ventilation via an AEC as being
associated with pneumothorax, pneumomediastinum, pneumoperitoneum,
cardiovascular collapse and death. Three other case series
(n=96) reported uncomplicated AEC oxygen insufflation.
Unfortunately this literature review exposes the fact that many of
the aids & devices that we may rely upon for critical
procedures, such as difficult airway management, have not been
rigorously tested prior to entering the marketplace.
Take home message: The efficacy of administering oxygen via an AEC
during airway management is unproven compared with standard oxygen
therapies however, when used for this indication, there have been
multiple instances of pulmonary barotrauma resulting in significant
patient morbidity and mortality.
See also:
June 2009 (3)
2. Neurological deficit after a peripheral
regional anaesthetic: flying on instruments, the black box, crash
investigation and other aeronautics.
Editorial: Anaesthesia. 2011 Jun;66(6):435-8.
Ultrasound-guided interscalene blocks: understanding where to
inject the local anaesthetic. Spence BC et al.
Anaesthesia. 2011 Jun;66(6):509-14.
An article by Spence compares US guided intra-plexus and
peri-plexus needle tip placement for single injection interscalene
blocks in 170 patients. Interestingly, the block onset in
both sensory and motor distributions was similar. The
investigators feel that this finding suggests that injections
further from nerves may be safer and yet as effective. The
accompanying editorial highlights the fact US-guided blocks have
recently disproven two long-held beliefs that guided peripheral
nerve stimulation: firstly, that if no motor response was
elicted by an insulated needle delivering 0.5 mA, the tip could not
be intraneural and secondly, that an intra-neural injection would
result in postoperative neurological deficit. However,
although US has revealed the pitfalls of peripheral nerve
stimulation guided blockade, it does not provide a fail-safe method
of ensuring nerve trauma does not occur. Some experts have
suggested that pressure measurement during injection may enhance
the safety of blocks by alerting the practioner when the needle tip
is within a non-compliant fascicle. It is reassuring that
recent evidence suggests that the incidence of block related
permanent nerve damage is low: ~1 in 2000 for a neuropraxia
and ~1 in 4000 for a deficit lasting longer than 6 months.
The editorial highlights that the risk of neurological deficit from
ANY cause is much higher yet the management of unexpected
postoperative neurological deficit often inadequate. The
author suggests a 3 step team process to diagnosis and management
an acute, severe neurological deficit. Firstly, imaging,
guided by a radiologist, should be undertaken. Secondly a
neurologist should be consulted and, if appropriate, may provide an
introduction to neurophysiologists who can then recommend nerve
conduction studies and EMG if relevant.
Take home message: Intra-plexus and peri-plexus needle tip
placement for single injection interscalene blocks are associated
with similar onset times in both the motor and sensory
distributions.
See also:
Dec 2009 (4)
AIRWAY
Rao V et al. Mask ventilation in edentulous and bearded
patients. Anesth Analg. 2011 Jun;112(6):1513-4
Yuan YJ et al. Facilitating combined use of an Airtraq�
optical laryngoscope and a fiberoptic bronchoscope in patients with
a difficult airway. Can J Anaesth. 2011 Jun;58(6):584-5;
author reply 585.
GENERAL TOPICS
Editorial: Ng A et al. Hypoxaemia associated with
one-lung anaesthesia: new discoveries in ventilation and
perfusion. Br J Anaesth. 2011 Jun;106(6):761-3
Ruetzler K et al. Randomized clinical trial comparing
double-lumen tube and EZ-Blocker for single-lung ventilation.
Br J Anaesth. 2011 Jun;106(6):896-902.
Estebe JP et al. The pneumatic tourniquet: mechanical,
ischaemia-reperfusion and systemic effects. Eur J
Anaesthesiol. 2011 Jun;28(6):404-1
Buchanan FF et al. Effect of patient sex on general
anaesthesia and recovery. Br J Anaesth. 2011
Jun;106(6):832-9
Editorial: Tram�r MR. The Boldt debacle. Eur J
Anaesthesiol. 2011 Jun;28(6):393-5
Editorial: Streitberger K et al. Evidence for the
efficacy of acupressure for preventing post-operative nausea and
vomiting: an ongoing debate. Eur J Anaesthesiol. 2011
Jun;28(6):396-8.
OBSTETRICS
- Editorial: Douglas MJ et al. The obstetric airway:
things are seldom as they seem. Can J Anaesth. 2011
Jun;58(6):494-8
McKeen DM et al. Difficult and failed intubation: Incident
rates and maternal, obstetrical, and anesthetic predictors.
Can J Anaesth. 2011 Jun;58(6):514-24..
PAEDIATRICS
Editorial: Radcliffe J et al. Learning disability in
children as an outcome in anesthesia and analgesia research.
Anesth Analg. 2011 Jun;112(6):1262-4.
Editorial: Sun LS. Labor analgesia and the developing
human brain. Anesth Analg. 2011 Jun;112(6):1265-7
Flick RP et al. Neuraxial labor analgesia for vaginal
delivery and its effects on childhood learning disabilities.
Anesth Analg. 2011 Jun;112(6):1424-31.-
Editorial: Deshpande JK. Cause and effect or
conjecture? A call for consensus on defining
"anesthesia-related mortality". Anesth Analg. 2011
Jun;112(6):1259-61.
van der Griend BF et al. Postoperative mortality in children
after 101,885 anesthetics at a tertiary pediatric hospital.
Anesth Analg. 2011 Jun;112(6):1440-7.
Davidson AJ et al. Awareness in children: a secondary
analysis of five cohort studies. Anaesthesia. 2011
Jun;66(6):446-54.
PAIN
Editorial: Myles PS et al. Measuring pain and analgesic
response. Eur J Anaesthesiol. 2011 Jun;28(6):399-400
Rothwell MP et al. Oral oxycodone offers equivalent analgesia
to intravenous patient-controlled analgesia after total hip
replacement: a randomized, single-centre, non-blinded,
non-inferiority study. Br J Anaesth. 2011
Jun;106(6):865-72
McNicol ED et al. Single-dose intravenous paracetamol or
propacetamol for prevention or treatment of postoperative pain: a
systematic review and meta-analysis. Br J Anaesth. 2011
Jun;106(6):764-75.
REGIONAL ANAESTHESIA
Niraj G et al. Comparison of analgesic efficacy of subcostal
transversus abdominis plane blocks with epidural analgesia
following upper abdominal surgery. Anaesthesia. 2011
Jun;66(6):465-71.
PERIOPERATIVE MEDICINE
Editorial: Gawande AA et al. Critical need for
objective assessment of postsurgical patients.
Anesthesiology. 2011 Jun;114(6):1269-70.
Reynolds PQ et al. Expansion of the surgical Apgar score
across all surgical subspecialties as a means to predict
postoperative mortality. Anesthesiology. 2011
Jun;114(6):1305-12
Editorial: McDonagh DL. Perioperative stroke: where do
we go from here? Anesthesiology. 2011 Jun;114(6):1263-4
Mashour GA et al. Perioperative stroke and associated
mortality after noncardiac, nonneurologic surgery.
Anesthesiology. 2011 Jun;114(6):1289-9
Editorial: Peden CJ. Emergency surgery in the elderly
patient: a quality improvement approach. Anaesthesia. 2011
Jun;66(6):440-5
Editorial: Miller TE et al. Poor adoption of
hemodynamic optimization during major surgery: are we practicing
substandard care? Anesth Analg. 2011 Jun;112(6):1274-6.
Gurgel ST et al. Maintaining tissue perfusion in high-risk
surgical patients: a systematic review of randomized clinical
trials. Anesth Analg. 2011 Jun;112(6):1384-91
Hamilton MA et al. A systematic review and meta-analysis on
the use of preemptive hemodynamic intervention to improve
postoperative outcomes in moderate and high-risk surgical
patients. Anesth Analg. 2011 Jun;112(6):1392-402.
Editorial: Chung F et al. Sleep medicine and
anesthesia: a new horizon for anesthesiologists.
Anesthesiology. 2011 Jun;114(6):1261-2
Editorial: Crosby G et al. Preoperative cognitive
assessment of the elderly surgical patient: a call for
action. Anesthesiology. 2011 Jun;114(6):1265-8
Evered LA et al. Preexisting cognitive impairment and mild
cognitive impairment in subjects presenting for total hip joint
replacement. Anesthesiology. 2011 Jun;114(6):1297-304
Editorial: Sladen RN. Chronic kidney disease: the
silent enemy? Anesth Analg. 2011 Jun;112(6):1277-9
Ackland GL et al. Chronic kidney disease and postoperative
morbidity after elective orthopedic surgery. Anesth Analg.
2011 Jun;112(6):1375-81.
Written by Maryanne Balkin, July 2011
Feedback welcome: M.Balkin@alfred.org.au
Disclaimers:
1 Best
attempts are made to include articles representative of recent
publications but no attempt is made to include every important
article.
2 Commentary
& take home message is only one of many possible
opinions/interpretations of the literature.
For other editions of journal watch:
http://www.anaesthesiacases.com.au/cpd