Resting blood pressure (BP) is inversely related to pain sensitivity in individuals free of chronic pain, reflecting homeostatic interactions between cardiovascular and pain modulatory systems. Several laboratory studies indicate that BP-related hypoalgesia is diminished in chronic pain patients, suggesting dysfunction in these interacting systems. Separate epidemiological findings reveal elevated hypertension prevalence in the chronic pain population. ⋯ Presence of chronic pain was associated with significantly increased odds of comorbid hypertension (P<.001). Within the chronic pain group, higher chronic pain intensity was a significant predictor of positive hypertension status beyond the effects of traditional demographic risk factors (P<.05). Results are consistent with the hypothesis that increased hypertension risk in the chronic pain population might be linked in part to chronic pain-related dysfunction in interacting cardiovascular-pain modulatory systems.
Randomized Controlled Trial
Why should I read this?
The cuffed vs non-cuffed ETT debate for children and neonates is largely settled, demonstrating the superiority of modern cuffed tubes over their historical, uncuffed forbears. Nevertheless, despite reliable evidence to the contrary, many general anaesthetists still prefer uncuffed tubes for children.
Give me the quick overview
Shah & Carlisle explore the accumulated evidence supporting the shift to cuffed endotracheal tubes by paediatric anaesthetists, both in neonates and older children.
They challenge historical airway anatomy & physiology myths that once encouraged the use of uncuffed ETTs in children, and the questionable reliability of the widely-used Cole formula for tube size prediction (size = age/4 + 4; correct in only 50-75%).
The development of Weiss et al.'s Microcuff™ tube represents a watershed moment in addressing concerns of paediatric airway trauma from cuffed ETTs, resulting in improved ETT function without any increase in stridor.
More recently, Chamber's 2018 RCT compared cuffed and uncuffed ETTs in children undergoing elective general anaesthesia, and found that cuffed tubes improved ventilation and reduced short-term post-operative respiratory complications, in addition to decreasing tube changes.
Addressing concern for increased work-of-breathing and higher inspiratory pressures when using a 0.5 mm smaller ID tube, Shah & Carlisle note Thomas et al.'s 2018 laboratory study showing any such effect is easily compensated for with pressure support and automatic tube compensation.
Similarly, the authors also note that there has been no demonstrated evidence of an increased incidence of subglottic stenosis in children using cuffed ETTs.
Finally, Shah & Carlisle report on their updated meta-analysis, showing that cuffed tracheal tubes in children result in fewer tube changes and less sore throat, but no difference in risk of laryngospasm.
Using a modern, Microcuff™ or equivalent cuffed ETT that is 0.5 mm smaller in size than an equivalent uncuffed tube, offers functional, ventilation and safety benefits.summary
LMA and Caesarean – why should I care?
There is a small attitude change underway in the use of supraglottic airway devices (SGA) in obstetric anaesthesia. While there is already an appreciation of their role in obstetric airway rescue, we now see a shift in some countries to use an SGA as the primary airway choice for Caesarean section under general anaesthesia.
Anaesthesiologists need to be aware of this attitudinal shift, and importantly appreciate the inherent compromises and uncertainties driving it.
In this editorial, Metodiev & Mushambi review changing attitudes toward obstetric airway preference, the realities of maternal aspiration risk, and several large studies suggesting acceptable safety when using a SGA for Caesarean GA.
The tension between airway and aspiration
It is well accepted that regional anaesthesia for Caesarean section is overwhelmingly the best choice, driven first by the historical experience of maternal general anaesthesia risk. The very features that underline this safety improvement are also those in tension when considering endotracheal intubation or SGA: risk of failed intubation versus aspiration.
Studies showing safety
Several retrospective, prospective and randomised studies totalling more than 8,000 patients have concluded that in these populations, SGA use (mainly 2nd generation devices, such as ProSeal™ or LMA Supreme™) was not associated with any greater risk of aspiration. This includes both the single largest study investigating 3,000 women (Halaseah 2010), and two RCTs (Yao 2019 & Li 2017), none of which identified any cases of aspiration (although there was a single regurgitation).
So on the surface, SGA use appears arguably safe, particularly with careful patient selection. Among the studies, generally obese patients and those with reflux were excluded, muscle relaxants were frequently used, an orogastric tube was inserted, and cricoid pressure was used at least for some periods of airway intervention.
And yet we do know from NAP4 (2011) that aspiration is a real danger, accounting for 50% of anaesthesia-related deaths.
Is gastric ultrasound the answer?
No. Next question... 😉
While gastric ultrasound shows some utility in quantifying residual gastric volume, it is 1. Not possible to equate this to aspiration risk in pregnant patients, 2. Technically difficult in the pregnant patient.
They conclude that...
"...there is insufficient evidence to recommend universal or selective replacement of tracheal tubes with SGA devices during general anaesthesia for Caesarean delivery. Aspiration remains the main concern."
And before you get too excited by the lack of observed aspiration in these large studies, as Metodiev & Mushambi note, many of the studied populations were Asian and Middle Eastern, having different diets and obesity prevalence than Europe, Oceania and North America.summary