Anaesthesia and intensive care
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Anaesth Intensive Care · Jan 2014
Case ReportsIntraoperative anaphylaxis to sugammadex and a protocol for intradermal skin testing.
Sugammadex is a selective binding agent for aminosteroid neuromuscular blockers whose use is increasing in anaesthetic practice. We present three cases of severe anaphylaxis coincident with sugammadex administration. ⋯ As all patients were administered sugammadex to reverse neuromuscular blockade with rocuronium, we considered that sugammadex-rocuronium complexes were a potential unique allergen. In the two patients who were additionally tested with a rocuronium-sugammadex (3.6:1 molecular ratio) mixture, the wheal-and-flare response was significantly attenuated.
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We describe a case of a patient undergoing open abdominal aneurysm surgery who developed a severe, life-threatening allergic reaction immediately after administration of sugammadex. The manifestation was purely a cardiovascular collapse. ⋯ Sugammadex was confirmed as the cause of the anaphylaxis by a positive intradermal allergy test (25 mm diameter response to 1:100 dilution), with a normal saline control and a negative response to the other drugs used during the event. This case report is a reminder that the use of sugammadex is associated with rare but serious risks.
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Anaesth Intensive Care · Jan 2014
Randomized Controlled TrialA randomised controlled trial of parecoxib, celecoxib and paracetamol as adjuncts to patient-controlled epidural analgesia after caesarean delivery.
The benefit of combining non-opioid analgesics with neuraxial opioids for analgesia after caesarean delivery has not been clearly established. Larger doses of paracetamol or cyclooxygenase-2 inhibitors have not been evaluated. A randomised, double blind, double-dummy, parallel group placebo-controlled clinical trial was conducted among women having elective caesarean delivery under spinal anaesthesia, followed by pethidine patient-controlled epidural analgesia. ⋯ There were no differences between groups for pethidine consumption, based on either intention-to-treat (median 365, 365, 405 and 360 mg in groups C, PC, PA and PCPA respectively, P=0.84) or per protocol analysis (17 major violations). Dynamic pain scores did not differ between groups but requirement for, and dose of, supplementary oral tramadol was least in group PCPA (incidence 23% versus 48%, 70% and 58% in groups C, PC and PA respectively, P=0.004). The addition of regular paracetamol, cyclooxygenase-2 inhibitors or both to pethidine patient-controlled epidural post-caesarean analgesia did not provide a pethidine dose-sparing effect during the first 24 hours.
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Anaesth Intensive Care · Jan 2014
Randomized Controlled Trial Comparative StudyRandomised comparison of an end-hole, triple-hole and novel six-hole catheter for continuous interscalene analgesia.
Epidural analgesia studies and a recent continuous peripheral nerve block study suggest multi-hole perineural catheters perform better than end-hole catheters. Confounding catheter positioning issues limit interpretation of the latter study. One hundred and fifty-six patients receiving an anterolateral interscalene catheter for elective shoulder surgery were randomised to three groups: following out-of-plane ultrasound confirmation of the needle tip immediately lateral to the C5/6 roots, an end-hole (n=52), triple-hole (n=53) or six-hole (n=51) non-stimulating catheter was positioned 3 cm beyond the needle tip. ⋯ Catheter threading difficulty was more common for the square-tipped end-hole catheters (end-hole=19% versus triple-hole=6%, six-hole=0%, P >0.001). This study found no evidence to support catheter orifice configuration significantly affecting the quality of continuous peripheral nerve blockade. These findings are in contrast to epidural catheter studies, and suggest that anatomical factors have a significant bearing on whether multi-orifice catheters confer advantage over the single-orifice design.
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Anaesth Intensive Care · Jan 2014
ReviewPreventing cerebral oedema in acute liver failure: the case for quadruple-H therapy.
Severe cerebral oedema is a life-threatening complication of acute liver failure. Hyperammonaemia and cerebral hyperaemia are major contributing factors. A multimodal approach, which incorporates hyperventilation, haemodiafiltration, hypernatraemia and hypothermia (quadruple-H therapy), may prevent or attenuate severe cerebral oedema. ⋯ The administration of concentrated saline increases serum tonicity and further reduces cerebral swelling. In addition, the pathologically increased cerebral blood-flow is further attenuated by therapeutic hypothermia. The combination of all four treatments in a multimodal approach may be a safe and effective means of attenuating or treating the cerebral oedema of acute liver failure and preventing death from neurological complications.