A growing collection of landmark papers relevant to anaesthesia and anesthesiology.
These papers are practice changing and hold current, ongoing significance beyond their historical importance.
This is a dynamic and changing document that will be updated, pruned and added to as appropriate. Many of these papers have free full-text provided by the publisher because of their significance.summary
The potential for dexamethasone and other glucocorticoids to prolong peripheral nerve blocks was first noted almost 20 years ago.
While the effect has been observed with several different blocks (upper & lower extremity, and even TAP blocks), the clinical significance varies and several questions still remain:
Is the effect exclusive to perineural dexamethasone? Several studies have observed similar effects for both IV and perineural dexamethasone (though less profound than other papers).
Is the effect safe? This is perhaps the most concerning, as there are suggestions that the effect may represent an enhancement of the well-known neurotoxicity of local anaesthetic agents.
An extensive collection of research debunking a range of myths and misconceptions regarding our use of 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
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.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
...and 2 more notes