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Anesthesia and analgesia · Aug 2013
Multicenter StudyReversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block.
Sugammadex use does not avoid either the need or benefit of neuromuscular monitoring, although it does result in less residual neuromuscular block than neostigmine reversal.
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Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. ⋯ Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.
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To evaluate changes in cerebral tissue oxygen index (TOI) values under the beach chair position before and during general anesthesia in surgical patients with or without cardiovascular risk factors. ⋯ The beach chair position under general anesthesia did not alter cerebral oxygenation in patients with or without cardiovascular risk factors showing normal preoperative cerebral TOI values when the mean blood pressure was maintained above 60 mm Hg. The careful management using the cerebral oxygenation monitoring appears to maintain cerebral perfusion in the beach chair position during general anesthesia.
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What did they find?
This review by Patel, Robertson & McConachie identified 21 published cases of inadvertent spinal TXA administration. Notably 10 patients died, and almost all suffered life-threatening side effects.
What are the common signs?
- Block failure.
- Severe back and buttock pain (universal).
- Seizures.
- HT, tachycardia, arrhythmias, CVS collapse.
How should it be managed?
There are three components to managing intrathecal TXA:
- Treating TXA-induced seizures with anticonvulsants: magnesium; benzodiazepines; barbiturates (thiopentone); phenytoin; possibly propofol. Thiopentone infusion was frequently required to terminate seizures.
- Mitigate TXA neurotoxic effects: maintain head-up; CSF lavage to dilute TXA, infusing crystalloid at an interspace higher than an IT needle draining CSF, 10mL for 10mL, repeated up to 4 times.
- Haemodynamic monitoring & support
How does this happen?
In almost all cases ampoule identification error was the primary cause.
Human factor contributions identified were:
- Failure to check ampoule label.
- Similar ampoule appearance.
- Spinal catheter mistaken for IV (1).
- Lack of drug handling and storage policies.
- Storage of tranexamic acid with LA or lack of physical separation.
- Underestimating potential for error.
summary"All errors could have been prevented..."
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This review considers the current position of nitrous oxide in anaesthetic practice and balances potential beneficial and disadvantageous effects. The classic adverse characteristics of nitrous oxide, such as diffusion hypoxia, expansion of gas-filled spaces, and postoperative nausea and vomiting, are often cited as reasons to avoid this old drug. Recent concerns regarding neurotoxicity, adverse cardiovascular outcomes, and wound complications have further hardened many practitioners against nitrous oxide. ⋯ While we await the outcome of large studies including ENIGMA-II, many clinicians have already decided against this agent. The authors argue that this abandonment may be premature. Clinical Trial Registration None required.