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summary
1
Collection: Left-lateral tilt, aortocaval compression and caesarean section
Is the conventional assumption that left-lateral tilt and uterine displacement avoids aortocaval compression during Caesarean section actually valid?
50 years of assumed orthodoxy is challenged by studies showing that:
• True aortal compression is relatively uncommon (Higuchi 2015, Lee 2012).
• Caval compression is probably near-universal, but also usually not improved by a mere 15 degree tilt. (An impractical 30 degrees is more likely required for meaningful impact!) (Palmer 2015).
• Caval compression probably has limited haemodynamic or fetal consequences in the fit, well, term parturient (Higuchi 2015; Lee 2012).
• Judicious use of vasopressor infusions may obviate the need for traditional uterine displacement (Lee 2017; Farber 2017).
Time to change practice then?
Not quite yet...
  Daniel Jolley
pearl
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Duration of rocuronium action directly correlates with BMI.
Takahata O, Takahoko KI, Sasakawa T et al. Duration of the action of rocuronium in patients with BMI of less than 25: An observational study. Eur J Anaesthesiol. 2018 Nov 1; 35 (11): 863-866.
  Daniel Jolley
pearl
1
Intraoperative dexamethasone reduces the incidence of postoperative sore throat for up to 24 hours and postoperative hoarseness for 1 hour.
Zhao X, Cao X, Li Q. Dexamethasone for the prevention of postoperative sore throat: a systematic review and meta-analysis. J Clin Anesth. 2015 Feb 1;27(1):45-50.
  Daniel Jolley
pearl
1
Use of smaller-sized ETT results in less post-operative sore throat in female patients.
Hu B, Bao R, Wang X et al. The size of endotracheal tube and sore throat after surgery: a systematic review and meta-analysis. Plos One. 2013 Jan 1;8(10):e74467.
  Daniel Jolley
pearl
1
Women experience less frequent and less severe sore throat postoperatively after intubation with a size 6.0 ETT versus size 7.0.
Jaensson M, Olowsson LL, Nilsson U. Endotracheal tube size and sore throat following surgery: a randomized-controlled study. Acta Anaesthesiol Scand. 2010 Feb 1;54(2):147-53.
  Daniel Jolley
pearl
1
Optimal intraoperative PEEP varies among patients. Individualizing PEEP reduces post-operative atelectasis.
Pereira SM, Tucci MR, Morais Caio C A CCA et al. Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis. Anesthesiology. 2018 Dec 1; 129 (6): 1070-1081.
  Daniel Jolley
summary
0
Case report from Yamaguchi, Japan describing a confirmed sugammadex anaphylaxis in a 50kg woman receiving 4mg/kg sugammadex.
Notably, follow-up skin prick testing strongly suggests #1 hypersensitivity to free sugammadex molecules, rather than the sugammadex-rocuronium complex, and #2 hypersensitivity appears to be dose-related.
Nakanishi T, Ishida K, Utada K et al. Anaphylaxis to sugammadex diagnosed by skin prick testing using both sugammadex and a sugammadex-rocuronium mixture. Anaesth Intensive Care. 2016 Jan 1; 44 (1): 122-4.
  Daniel Jolley
summary
1
Why is this important?
First, because it identifies new novel risk factors for residual neuromuscular block (experienced surgeon, non-CRNA anesthesia provider...) and secondly, because the subtext reveals the lengths our specialty goes to avoid simply monitoring using qualitative NMB monitoring (TOFR)!
What did they find?
Rudolph et al. created a REsidual neuromuscular block Prediction Score (REPS) using Massachusetts General PACU data, applying covariate analysis to identify 10 risk factors, some more surprising than others:
1. Hepatic failure
2. Neurological disease
3. High-neostigmine dose > 60 mcg/kg
4. Metastatic solid tumour
5. Female sex
6. Less than 120 min between NMBD administration and extubation
7. Aminosteroid NMBD
8. BMI more than 35
9. Absence of nurse anaesthetist (CRNA)
10. Having an experienced surgeon
Be smart:
These risk factors might suggest patients who need more careful monitoring, but you will probably be better off just using qualitative monitoring routinely. The utility of REPS itself is only modest with NPV & PPVs of 85% each.
The other takeaway is that rNMB is still demonstratably common, occurring in 20% of this cohort!
Rudolph MI, Ng PY, Deng H et al. Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file. Eur J Anaesthesiol. 2018 Nov 1; 35 (11): 883-892.
  Daniel Jolley
pearl
1
The majority of anesthesia-related cardiac arrests are due to respiratory events.
Hohn A, Machatschek JN, Franklin J et al. Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: A 6-year observational study from a tertiary care university hospital. Eur J Anaesthesiol. 2018 Apr 1; 35 (4): 266-272.
  Daniel Jolley
comment
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While there is both utility and some interesting insights from the LAS VEGAS risk score research, it also seems to have largely confirmed that higher risk patients, having more invasive or major surgery, and those who misbehave intraoperatively are more likely to experience postoperative pulmonary complications...
Neto Ary Serpa AS From the Hospital Israelita Albert Einstein, São Paulo, Brazil (ASN, LGVC), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands (SN, LGV da Costa, Hemmes Sabrine N T SNT et al. The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study. Eur J Anaesthesiol. 2018 Sep 1; 35 (9): 691-701.
  Daniel Jolley