Knowledge
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Calabadions are heterocyclics molecule that offers rapid and complete reversal of both aminosteroids, such as rocuronium and vecuronium, and benzylisoquinoline NMBDS, such as atracurium and cisatracurium.
Notably, calabadion 2 binds rocuronium 89 times stronger than sugammadex. Additionally it also binds etomidate and ketamine.
Calabadions are still undergoing pre-human animal testing, and so are some time away from entering clinical practice.
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A collection of the top 20 most cited pediatric anesthesiology papers of all time from Ravi Tripathi's excellent 2011 study:
Tripathi, R. A bibliometric search of citation classics in anesthesiology. BMC Anesthesiol. 2011 Jan 1;11:24.
These are probably 20 articles that every anaesthetist or anesthesiologist with even a small component of pediatric practice should be aware of – not necessarily because they are still practice changing, but because they our foundational to our current understanding and practice of pediatric anesthesia.
These articles help to both show where we have come from, and where we may be heading.
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The remifentanil PCA for labour analgesia controversy continues...
Those advocating its first-line use point to reassuring evidence of maternal satisfaction and acceptability, reduced epidural rates, and some suggestion of reduced instrumental delivery rates.
For the negative, the ongoing safety concerns created by routine use of remifentanil PCAs are foremost, particularly given how uneven hospitals can be at implementing best safety practices. Observed rates of significant desaturation range from 25-70%, in addition to potential neonatal effects.
The greatest challenge facing the remiPCA advocates, is that the labour epidural is still the most effective form of labour analgesia, and has only improved over the decades as safety has been both maintained and increased.
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Early in the COVID pandemic, diagnostic testing relied entirely on precise-but-expensive PCR testing. Late in 2020 the Lateral Flow Testing techniques, already widely used for home-pregnancy tests and similar, were developed for SARS-CoV-2 antigens, leading to COVID-19 Rapid Antigen Tests (RATs).
While cheap, scalable and able to give a result in 10-15 minutes, they were initially seen mostly as a supplement to PCR testing, with less accuracy. Although true that RATs have lower sensitivity than SARS-CoV-2 PCR – most licensed-RATs have sensitivity 80-95% – today this is both less important, and possibly even a strength of RATs over PCR.
Early in the pandemic the role of testing has primarily about diagnosis, in those either symptomatic or pre-symptomatic. Viral presence was practically assumed to be synonymous with contagion. Today with over half a billion cumulative COVID cases worldwide and counting, along with access to effective vaccines and antivirals, it is often more useful to know whether an individual is infectious or not at a discrete moment in time.
Growing research over the last 12 months shows that adequately-sensitive RATs are effective at identifying infectious individuals, even if the high-sensitivity of PCR testing identifies viral particles in those who are infected but otherwise non-infectious (either pre-infectious, or post-infectious with ongoing viral shedding).
PCR positive results with cycle thresholds (ie. number of thermal cycles of RNA replication required before fluorescence is detected) above 25-30 have good correlation with being non-infectious (ie. unable to culture virus). Adequately approved & validated RATs (by FDA, TGA, MHRA, etc.) have very high sensitivity at CT less than this 25-30 range, depending on the study and specific manufacturer.
The bottom line...
An adequately-validated RAT, when correctly performed, is likely a sensitive indictor of individual infectiousness at that specific moment in time. The reliability of a negative RAT will be improved if using the same manufacturer and technique as a RAT previously positive test, and more so if there are several subsequent negative RATs.
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