Although there is some evidence of different efficacy among commonly used vasopressors, translating this to clinically-significant outcome differences is still uncertain.
Singh's 2020 Bayesian network meta-analysis is the most comprehensive study to date investigating this issue. The researchers concluded that norepinephrine, metaraminol, and mephentermine showed the lowest probability of adverse neonatal acid-base effects, and ephedrine showed the greatest.
Previously phenylephrine infusion has been the consensus recommendation.
Nonetheless, other than ephedrine which should not be a first-choice pressor during Caesarean section, there is not enough evidence to strongly recommend one pressor over another. Clinical familiarity and institutional availability are probably the most important factors when choosing a vasopressor.summary
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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