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Three interesting recent studies looking at specific choices around anaesthetic technique. In the Canadian Journal of Anesthesia, da Silveira reviews the benefits of opioid-free laparoscopic surgery; in the Journal of Cardiothoracic and Vascular Anesthesia, Ford goes deep on the pros and cons of different anaesthetic techniques for AF ablation procedures; and finally in the JCA, Liu reports on a single-centre RCT investigating the beneficial effects of LMAs on atelectasis.

Opioid-Free Laparoscopic Surgery: Less Nausea, Similar Pain Control

An interesting meta-analysis from da Silveira et al. explores whether we can effectively manage minimally invasive abdominal surgery without using opioids - an important question given how common opioid-related side effects are.

This was a comprehensive systematic review and meta-analysis of 26 randomised controlled trials, including 2,025 patients. The researchers specifically compared opioid-free versus opioid-containing anesthesia in minimally invasive abdominal surgeries. They were particularly interested in looking at side effects like PONV and bradycardia, as well as pain control and recovery times.

The results were quite interesting. The authors found that opioid-free anaesthesia:

• Reduced PONV by 45% (from 24% to 13% / RR CI 0.40 to 0.74).
• Led to slightly lower immediate postoperative pain scores (though not clinically significant).
• Required less postoperative opioid use in the first 2 hours.
• Showed no difference in recovery room length of stay.
• Showed no increase in bradycardia, a previously noted concern when using intraoperative dexmedetomidine.

Read more...

GA caesarean section & post-partum depression

This large study (Guglielminotti 2020) of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.

Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.

The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.

In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:

To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).

An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.

Keep it in perspective...

We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.

Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.

The take-home:

Just another reason to avoid GA CS when possible – but you already knew that, right?

"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."

Supraglottic airway training and manikins

Interesting prospective simulation & equipment study by way of the University of Freiburg. Schmutz et al. investigated how effective five different second generation supraglottic airway devices (SADs) performed in two common airway manikins: the TruCorp AirSim® and the crowd favourite, Laerdal's Resusci Anne® Airway Trainer™.

While ventilation was achieved in all SAD-manikin combinations, the Resusci Anne® Airway Trainer™ was associated with better and more consistent performance for SAD position, participant subjective assessment and ease of gastric tube insertion for most of the SADs. The TruCorp AirSim® did however achieve better leak pressures across most of the SADs (LMA® Supreme™, Ambu® AuraGain™, i-gel®, KOO™-SGA & LTS-D™).

But then, what are the implications for airway simulation training? The researchers correctly note that:

The most important quality of a manikin is the ability to simulate the real-world conditions and thus to give the trainee an authentic feedback.

The bottom line for SAD manikins?

While considering how manikin choice and SAD availability match with your aims for simulation training, the bigger picture is that the primary goal of any manikin-SAD coupling is real-life fidelity – and for that reason, participant subjective assessment is king. And so in this study at least, the Resusci Anne® Airway Trainer™ wins.

Read on for head rotation with LMAs & COVID vaccine persistence...

There have been some interesting papers recently exploring all-things endotracheal, relevant to anaesthesiologists, intensivists and emergency physicians alike.

Some challenge long-accepted dogma (ETT size), others confirm natural trends (cuffed paediatric tubes), or delve into ventilation physiology long forgotten by some of us (the ventral shift...).

Here's a brief stroll through five articles that may challenge your practice.

Choose smaller...

First, Karmali & Rose challenge the dogma surrounding endotracheal tube sizing in adult anaesthesia. They explore both the functional consequences of ETT size, good and bad, as well as the implications for airway trauma.

They describe how a modern ETT ≥ 6.0mm ID will accomodate most intraluminal devices, and in fact smaller sizes might even facilitate some airway procedures. Similarly, inspiratory and expiratory flow dynamics of smaller ETTs are inconsequential for most fit and healthy patients.

Noting that there is wide individual variation in tracheal dimensions, such that some patients are poorly served by a traditional ETT-size choice, they highlight the correlation between ETT size and airway trauma, hoarseness and sore throat, noting that for many patients a 'large' ETT offers little practical benefit.

"Instead of opting for ‘the largest tube that the larynx will comfortably accommodate’, we perhaps should consider using the smallest tube which permits the safe conduct of anaesthesia."

For routine anaesthesia of ASA 1 & 2 patients, an ETT sized 6.0-7.0 mm is probably the best balance between ventilation needs and airway trauma.

Don't cough

Yang et al.'s high quality meta-analysis explores the use of intravenous lidocaine/lignocaine to reduce a common, but potentially significant post-operative problem: coughing on extubation. Both coughing (reported incidence 15-94%) and post-operative sore throat (21-72%) are common among surgical patients.

This meta-analysis of 16 trials (though only 1,516 total subjects) showed a significant reduction in cough RR 0.64 (0.48-0.86 & NNT=5), and post-operative sore throat RR 0.46 (0.32-0.67), though no difference in laryngospasm, adverse events or time to extubation when using modern volatile agents.

However, they could make no clear recommendation of optimal timing or dose of lidocaine – although past reviews had found suggestion of a dose-effect, settling on 1.5 mg/kg as the best choice (Clivio et al. 2019).

Regardless, a simple intervention with peri-operative IV lidocaine reduces coughing on extubation and reduces post-operative sore throat, without any apparent increase in adverse events.

Read on for more ETT tidbits...

Ah, videolaryngoscopes – wonderful toys increasingly common in operating rooms, intensive care units and emergency departments throughout the world.

After the first video laryngoscope was conceived by New York emergency physician Jon Berall in 1998, commercial success quickly followed with the 2001 Glidescope (designed by a vascular surgeon nonetheless!). Our love of the videolaryngoscope has grown ever since.

Like many anaesthetists and anesthesiologists I've used several different videolaryngoscopes over the past few years. The character that sets apart the videoscopes I like to use from those I do not is how well they enhance airway techniques I use every day rather than requiring a new technique specific to their device.

Overwhelmingly this comes down to how similar the laryngoscope is to a standard Macintosh blade rather than inventing a whole new shape. While there may be theoretical (or even real!) benefits to increasing the angle of the blade or adding extra conduits, when I have a difficult airway I want to augment the tools and techniques I use every day rather than change to something completely different. (When I want to change to something completely different I'll pick up a fibreoptic bronchoscope or something sharp!)

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