the metablog

Anesthesia and Analgesia's companion journal Anesthesia and Analgesia Case Reports is now indexed by metajournal, after being requested by our users.

A & A Case Reports has only been around since October 2013, after spinning off from the prestigious Anesthesia & Analgesia. It is now a standalone publication "...devoted exclusively to publishing cases that are educational and unusual."

You can jump in a browse the latest from A & A Case Reports among our indexed journals.

UPDATE:

Anesthesia & Analgesia has now evolved A & A Case Reports into A & A Practice – naturally, also indexed by metajournal!

Recently I needed to refer a patient preoperatively to a cardiologist for review. This is not an uncommon situation – one which happens thousands of times every week throughout the world. And yet it is a referral that anesthesiologists and anesthetists often do very poorly.

Avoid hypoxia, avoid hypotension?

We sometimes roll our eyes at recommendations made by physician colleagues: either providing unhelpful physiological parameters that we normally aim to maintain anyway (“avoid hypoxia?”), or stepping outside their expertise and boxing the anesthetist in by suggesting specific anesthetic techniques (“okay for a spinal”).

It is easy to be annoyed at both the lack of value this adds to our perioperative planning, as well as to the nonchalant ignorance of intraoperative medicine that it betrays. At the end of the day though, it’s our fault.

As Dr Andrew Silvers, a Melbourne cardiac and neuro-anesthetist recently opined, if your cardiologist replies with “avoid hypoxia and avoid hypotension” then YOU the anesthetist or anesthesiologist are at fault for not asking your cardiology colleague specific questions that will materially effect your perioperative planning.

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I have been intrigued since the first case reports appeared describing the use of sugammadex in rocuronium anaphylaxis. It sounds beautiful and elegant. A drug that magically mops up the offending molecule, removing it from circulation; quickly reversing the cardiovascular collapse as rapidly as it reverses muscle relaxation.

Unfortunately the truth is not quite as clear. Case reports showing impressive recovery of rocuronium anaphylaxis minutes after giving sugammadex are tempered by in vitro and in vivoimmunological studies suggesting an inability of sugammadex to modify a type 1 hypersensitivity reaction. The reality is likely somewhere in between, highlighting our limited understanding of anaphylaxis and our tendency to rush to over-simplified models of disease processes.

The story so far...

Jones and Turkstra first raised the possibility of using sugammadex to treat rocuronium anaphylaxis in 2010.¹ One year later Nolan McDonnell and team published the first case report of a remarkable use of sugammadex to manage rocuronium anaphylaxis.² McDonnell described a 33 year old having an elective diagnostic laparoscopy suffering anaphylaxis to rocuronium. After 19 min of conventional resuscitation, involving CPR, 3500 mL of intravenous fluids and 4 mg of epinephrine/adrenaline - 500 mg of sugammadex was given with remarkable effect:

"A dose of 500 mg (6.5 mg kg21) was given while chest compressions were in progress. The last dose of epinephrine had been given 4 min previously. Approximately 45 s after administration and while chest compressions were in progress, the patient suddenly opened her eyes and reached for her tracheal tube.

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Two studies caught my eye in Anesthesia & Analgesia. Teams from both Canada and South Korea independently investigated the anxiolytic value of using cartoons during paediatric induction.

The concept is not new, though this evidence is. The teams looked at different admission and induction types and in two distinctly different cultures, but showed very similar and significant benefits of using cartoons during pediatric induction.

Both papers highlighted the cost of perioperative anxiety in children. Anyone with even a passing pediatric anesthetic practice will agree with the reported 50% incidence of perioperative anxiety. Intense anxiety is associated with negative behavioural adaptations, some of which persist for months or longer. Severe childhood anxiety at anesthetic induction is almost as distressing for parents and anesthetist alike as it is for the poor child.

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Does sugammadex mean the end of suxamethonium for rapid sequence induction?

The answer: No, not by a long shot. Let me explain...

Suxamethonium (succinylcholine) is a depolarising muscle relaxant and often the first choice for muscle paralysis when a rapid sequence induction (RSI)¹ is needed. In addition to working quickly suxamethonium has a very rapid offset. For both anaesthetist and patient these are very desirable characteristics, although they come at a price. The price is suxamethonium's long list of side effects, ranging from minor to life threatening.² Were it not for it's life-saving fast-kinetics, suxamethonium's use in modern anaesthesia would no longer be justifiable.

Enter rocuronium

When rocuronium was first introduced in the 1990s it was met with excitement.³ Rocuronium's claim to fame was a very fast onset of action. Because it was less potent than other non-depolarising muscle relaxants of its generation (atracurium & vecuronium) a larger dose was required to achieve the same level of muscle paralysis. This dose created a large concentration gradient between plasma and the neuromuscular junction resulting in a faster onset of action. By giving a very large dose of rocuronium the anaesthetist could produce acceptable intubating conditions within 60 seconds, creation the first reliable modified rapid sequence induction.

Unfortunately the result of using such a large dose of rocuronium is a prolonged blockade. Even at lower doses (0.6 mg/kg 2x ED95) rocuronium produces a block that lasts at least five times longer than suxamethonium. At the 1.2 mg/kg (4x ED95) modified-RSI-dose of rocuronium the block duration stretches out even longer, reaching the duration of pancuronium. In the event of being unable to intubate, or worse unable to ventilate, prolonged blockade is disastrous. At this point rocuronium only provided half a solution for the replacement of suxamethonium.

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