Modern cuffed endotracheal tubes are a superior airway device for children and neonates, offering better ventilation mechanics, fewer tube changes, and fewer short-term respiratory complications, with no clinically significant downside.pearl
An extensive collection of research debunking a range of myths and misconceptions regarding the way we use neuromuscular blocking drugs.
- Myth 1: Modern relaxants are so reliable and predictable that monitoring is unnecessary.
- Myth 2: Post-op residual paralysis is neither common or important.
- Myth 3: Post-op residual paralysis is easy to identify.
- Myth 4: Sugammadex makes residual paralysis a non-issue. (it might, but only if it is routinely available and used!)
- Myth 5: Using propofol and remifentanil we can avoid relaxants for intubation all together.
- Myth 6: Neuromuscular blockade has no effect on BIS.
And bonus myth: deep relaxation is necessary for improving surgical access during laparoscopy.summary
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Possibly... but with some important caveats.
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.” – RD Miller (2007).
Sugammadex (Bridion®) is a remarkable drug – and the anaesthesia community has moved very quickly to embrace the potential of this first ‘selective relaxant binding agent’ (SRBA), despite it’s considerable cost.
Sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular from rocuronium. The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex’s onset is 10 times faster than neostigmine and three times faster than edrophonium.
Though beyond the parlour-trick of speedy action, or the possibility of rescuing a cannot-intubate-cannot-ventilate crisis – the biggest benefit of sugammadex for our patients may be in the dramatic reduction of post-operative residual paralysis. A common problem with serious consequences that the anaesthetic community has ignored for far too long.summary
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This growing collection of articles focuses on the evidence and expert guidance relating to the use of personal protective equipment (PPE) and the SARS-CoV-2 / COVID pandemic, with specific focus on PPE use by anaesthesiologists and anaesthetists.
More articles can found found via the PPE topic index.
What we know:
- Hospitals are frequent sources of outbreaks, among both staff, patients and the wider community.
- The quality of PPE evidence is low. Most evidence must be contextualised in consideration of expert opinion, and of the similarities between SARS-CoV-2 and SARS (SARS-CoV-1), MERS and influenza.
- Droplet-vs-airborne spread is a conceptual simplification and not a simple dichotomy. It is best understood as a spectrum of transmission risk.
- Time-exposed may be a more important consideration, especially in indoor, poorly ventilated spaces.
- PPE supply is globally limited, and so a pragmatic approach must be taken to its use, considering individual risk scenarios.
- Training, simulation and fit testing are critical for effective use of PPE.
- There are specific steps in the PPE donning & doffing workflow that are frequently associated with breaches exposing HCWs to infection. These require extra attention.
- Beyond cost, increasingly complex PPE (eg. PAPR, hoods, intubation boxes etc.) also increase the opportunity for PPE failure and exposure if users have not had adequate training in their use, and some PPE has been demonstrated to make intubation more difficult.
- The superiority of N95/P2 respirator masks over standard surgical masks for personal protection is unclear and unproven.