Knowledge
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First described in 1909, and then used for treatment of various types of headache and facial pain, the sphenopalatine ganglion block may offer a novel, simple and less-invasive treatment for post-dural puncture headache.
Very little has been published, primarily case studies, case series and retrospective audits. This limited data does however suggest that the technique may be as effective as the traditional epidural blood patch, though with significantly fewer risks.
Larger studies are however needed to properly define the block's role in treating PDPH.
Publications describe a trans-nasal approach, either sitting or supine. First topicalising with co-phenylcaine spray, then placing 2%-4% viscous lignocaine-soaked cotton-tipped applicators for 10 minutes, and finally repeated for a further 20 minutes. Success appears to range from 30-70%.
The mechanism of action may result from parasympathetic blockade at the SPG, resulting in reversal of the cerebral vasodilation thought to be associated with post dural puncture headache.
Several videos showing how simple SPG techniques:
- Roger Browning demonstrating one method for performing a topical SPG block.
- SPG Block for chronic migraine.
- SPG demonstration in the ED setting.
- SPG demonstration for family member to perform later at home.
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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.
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A collection of landmark research articles relevant to obstetric anesthesia. Some, such as Hawkins' audits of U.S. maternal deaths, are significant because of their historical impact. Others hold direct clinical relevance for practice today.
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The World Health Organisation's Surgical Safety Checklist has been adopted and implemented by many hospitals throughout the world: from large tertiary teaching hospitals in wealthy countries, to small hospitals in low-resource settings.
The benefits to each hospital however are likely not the same. Does the WHO SSC implemented in a hospital that already has a 'Time Out' process bring the same benefit, if any, as to a hospital for which the checklist was completely new? Possibly not.
Several studies across a wide range of health systems have shown conflicting results in terms of reducing morbidity, mortality and length of stay.
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Carbetocin is a long-acting synthetic oxytocin analog. Although a 100 mcg dose is currently recommended, there is still some question as to the ideal dose. Dosing as low as 20 mcg may possibly be equally effective.
Carbetocin is currently only recommended for use during elective cesarean delivery, obviating the need for a post-operative oxytocin infusion currently practiced in many countries. In some countries it is also used after vaginal delivery.
It is at least as efficacious as intravenous oxytocin, and may possibly be superior at reducing postpartum haemorrhage.
Due to it's comparatively high cost compared with oxytocin however, the economic benefit of avoiding post-operative oxytocin infusions has not been demonstrated.
In the scenario of emergency cesarean section after labor augmentation with oxytocin, a much larger dose is likely required and carbetocin cannot be recommended.
One study has suggested a post-operative analgesic benefit of carbetocin vs oxytocin, although the evidence base for this is far from conclusive.
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