Anaesthesia
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Review Meta Analysis
Prevention of hypotension after spinal anaesthesia for caesarean section: a systematic review and network meta-analysis of randomised controlled trials.
Why is this review important?
Although the importance of managing spinal anaesthesia-associated hypotension during caesarean section is well appreciated, there continues to be some debate over relative efficacy of interventions, whether vasopressors or fluid-loading.
Fitzgerald at al.'s review and network meta-analysis quantitatively compares a complete range of interventions across 109 studies.
What did they show?
Vasopressors were more effective at preventing intra-operative hypotension than fluid infusion techniques alone. Although there was no statistically significant difference in the incidence of hypotension among metaraminol, phenylephrine or noradrenaline/norepinephrine, metaraminol appeared the most effective (OR 0.04-0.26) and ephedrine the least (0.09-0.85). [vs Norepinephrine (OR 0.06-0.28), Phenylephrine (OR 0.11-0.29)]
Similarly, nausea and vomiting incidence was lower with vasopressors than other interventions. Phenylephrine more commonly caused bradycardia than other pressors, and ephedrine more commonly tachycardia. There was no significant difference in reactive hypertension.
The bottom-line...
The most effective way of preventing and managing maternal intraoperative hypotension is, as international guidelines already assert, alpha-agonist vasopressors. Using more complex protocols, such as phenylephrine or norepinephrine infusions, does not appear to offer benefit over metaraminol. Fluid infusions are at best a secondary intervention.
summary -
Review Meta Analysis
Prevention of hypotension after spinal anaesthesia for caesarean section: a systematic review and network meta-analysis of randomised controlled trials.
Why is this review important?
Although the importance of managing spinal anaesthesia-associated hypotension during caesarean section is well appreciated, there continues to be some debate over relative efficacy of interventions, whether vasopressors or fluid-loading.
Fitzgerald at al.'s review and network meta-analysis quantitatively compares a complete range of interventions across 109 studies.
What did they show?
Vasopressors were more effective at preventing intra-operative hypotension than fluid infusion techniques alone. Although there was no statistically significant difference in the incidence of hypotension among metaraminol, phenylephrine or noradrenaline/norepinephrine, metaraminol appeared the most effective (OR 0.04-0.26) and ephedrine the least (0.09-0.85). [vs Norepinephrine (OR 0.06-0.28), Phenylephrine (OR 0.11-0.29)]
Similarly, nausea and vomiting incidence was lower with vasopressors than other interventions. Phenylephrine more commonly caused bradycardia than other pressors, and ephedrine more commonly tachycardia. There was no significant difference in reactive hypertension.
The bottom-line...
The most effective way of preventing and managing maternal intraoperative hypotension is, as international guidelines already assert, alpha-agonist vasopressors. Using more complex protocols, such as phenylephrine or norepinephrine infusions, does not appear to offer benefit over metaraminol. Fluid infusions are at best a secondary intervention.
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Propofol-based total intravenous anaesthesia is well known for its smooth, clear-headed recovery and anti-emetic properties, but there are also many lesser known beneficial properties that can potentially influence surgical outcome. We will discuss the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol and their roles in pain, organ protection and immunity. We will also discuss the use of propofol in cancer surgery, neurosurgery and older patients.
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Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. ⋯ However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.
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Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. ⋯ In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.