Article Notes
- An intrathecal catheter may be inserted for the provision of analgesia and anaesthesia following inadvertent dural puncture during attempted epidural catheter placement. This decision must be made with consideration of potential risks and benefits (Grade C, moderate level of certainty).
- Whether using intermittent boluses or a continuous infusion technique, use the same local anaesthetic solution throughout labour (Grade I, low level of certainty).
- Maternal blood pressure should be checked every 5 min for 15 min following the first dose, and after every subsequent bolus given via an intrathecal catheter (Grade A, high level of certainty).
- As with epidural analgesia, sensory and motor block should be checked every hour during intrathecal catheter analgesia (Grade B, moderate level of certainty).
- Fetal heart rate should be continuously monitored during intrathecal analgesia (Grade B, moderate level of certainty).
- Top-ups of local anaesthetic for caesarean delivery should be given incrementally, with each bolus limited to 2.5 mg bupivacaine (or equivalent) (Grade I, low level of certainty).
- Extension of labour analgesia for caesarean delivery via an intrathecal catheter should be performed in an operating theatre (Grade B, moderate level of certainty).
- Non-invasive blood pressure, ECG and oxygen saturations should be monitored throughout the duration of intrathecal anaesthesia (Grade A, high level of certainty).
- All departments should have clear guidelines for the management of intrathecal catheters in labour and for delivery. These should highlight key risks, monitoring protocols and other safety measures (Grade A, low level of certainty).
- Only anaesthetists should administer top-ups through an intrathecal catheter, and connect, disconnect or reconnect the catheter and tubing (Grade A, low level of certainty).
- Anaesthetists should account for the dead space of the intrathecal catheter and filter when administering top-ups in labour or for operative delivery (Grade B, low level of certainty).
- An intrathecal catheter should be clearly labelled adjacent to the filter and on the front of any infusion pump (Grade A, low level of certainty).
- The multidisciplinary team (including any non-resident staff who may be called to attend the patient during labour or delivery), must be made aware of the intrathecal catheter through both verbal and written communication, including at every handover (Grade A, low level of certainty).
- Intrathecal catheters should be removed at the earliest opportunity following delivery to reduce the risk of accidental overdose and infectious complications (Grade B, low level of certainty).
- When patients who experience inadvertent dural puncture, with or without intrathecal catheter insertion, are discharged from hospital, follow-up should be in line with established guidance and include written information on headaches, ‘red flag’ symptoms, hospital contact information and communication with primary care (Grade B, low level of certainty).
This narrative review by Ford et al. examines how anaesthetic technique impacts the success of catheter ablation for atrial fibrillation (AF). With AF being the most common cardiac arrhythmia and ablation procedures increasingly common, understanding optimal anaesthetic approaches is crucial for improving patient outcomes.
The authors compare three key approaches: general anaesthesia (GA) versus conscious sedation, high-frequency jet ventilation (HFJV), and high-frequency low tidal volume ventilation (HFLTV).
The evidence strongly favours GA over conscious sedation, with one study showing significantly better arrhythmia-free rates at 17 months (88% vs 69%). Both HFJV and HFLTV show promise in improving catheter stability and procedural outcomes through reduced respiratory variability, though HFJV faces practical challenges including cost and training requirements.
While the review acknowledges the need for randomised controlled trials comparing different ventilation strategies, it makes a compelling argument for anaesthetic techniques that minimise ventilation variability. HFLTV might offer a practical middle ground, potentially providing similar benefits to HFJV without the associated costs and training demands.
Daniel Jolley
A comprehensive meta-analysis from Da Silveira examines whether minimally invasive abdominal surgery can be effectively managed without intraoperative opioids. Da Silveira and colleagues analysed 26 randomised controlled trials involving 2,025 patients, comparing traditional opioid-based anaesthesia with opioid-free techniques using alternatives like dexmedetomidine, ketamine, and lidocaine.
The results are compelling: opioid-free anaesthesia reduced postoperative nausea and vomiting by 45% (from 24% to 13%) without compromising pain control or increasing recovery time.
Notably, concerns about bradycardia with dexmedetomidine proved unfounded, with no significant difference in rates between the groups. The study also found slightly lower immediate postoperative pain scores and reduced opioid requirements in the first two hours after surgery.
While these findings strongly support opioid-free techniques for laparoscopic surgery, the authors note important caveats. The included trials used varying combinations of agents, making it difficult to recommend a standardised approach. Successfully implementing opioid-free anaesthesia requires expertise with multiple alternative agents and techniques - but the benefits, particularly in reducing post-operative nausea and vomiting, may be worth the learning curve.
Daniel Jolley
Recommendations:
Daniel Jolley