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pearl
1
In laparoscopic nephrectomy patients, early post-operative pain is associated with 30-day infectious complications.
Albers KI, van EV, Dahan A et al. Early postoperative pain after laparoscopic donor nephrectomy predicts 30-day postoperative infectious complications: a pooled analysis of randomized controlled trials. Pain. 2020 Jul 1; 161 (7): 156515701565-1570.
  Daniel Jolley
summary
1
Why is this important?
Indications for the use of laryngeal mask airways (LMAs) increasingly challenge our airway choice for surgical procedures where endotracheal intubation has been the norm. Thyroid surgery, with its limited anaesthetic access to the airway and potential for airway obstruction, has not typically been a first choice for LMA use.
Proponents point to avoiding muscle relaxants and reducing throat pain and laryngeal trauma as the main benefits.
What did they do?
Gong and team randomised 138 ASA 1 & 2 adults to either flexible (reinforced) LMA or intubation with an ETT (7.0 or 7.5 mm). Notably any patients with surgical complexity or BMI > 30 kg/m² were excluded. The study was single-blinded.
Concluding
The researchers reported the upper 95%-CI for estimated mean difference in peak airway pressure as +0.96 cmH₂O, and for endtidal-CO₂ +1.99 mmHg – neither of which are clinically significant.
They concluded that flexible-LMA was non-inferior to ETT in terms of PAP and ET-CO₂.
Hang on...
The relevance of this study to most thyroid surgical patients is however limited at best. Not only were common groups of patients excluded (ie. BMI > 30) but one of the major arguments for LMA use (avoiding muscle relaxants) was irrelevant: all patients were paralysed with rocuronium.
Further, in 7% of the LMA cases severe air-leak occured and the surgical team were asked to cease or reduce tracheal traction.
Be smart
Although the journal editors conclude in their Key Points that "FLMA is a safe alternative for experienced anesthesiologists in thyroid surgery" this seems quite a stretch given that this small study was neither powered for safety and only investigated airway ventilation performance as a narrow surrogate for acceptability.
Additionally the authors themselves highlight very real surgical concerns that LMA use can distort pharyngeal anatomy with serious consequences.
Not dissimilar to arguments for LMA use in GA caesarean section, the use of an LMA for thyroid surgery edges toward 'just because we can, does not mean we should'.
Gong Y, Wang J, Xu X et al. Performance of Air Seal of Flexible Reinforced Laryngeal Mask Airway in Thyroid Surgery Compared With Endotracheal Tube: A Randomized Controlled Trial. Anesth. Analg. 2020 Jan 1; 130 (1): 217-223.
  Daniel Jolley
pearl
1
Ultrasound-guided peripheral nerve blocks may yield better sensory and motor block, reduce supplementation & minor complications. Use of ultrasound alone is faster than when using with nerve stimulation.
Lewis SR, Price A, Walker KJ et al. Ultrasound guidance for upper and lower limb blocks. Cochrane Db Syst Rev. 2015 Sep 11; 2015 (9): CD006459CD006459.
  Daniel Jolley
pearl
1
Compared to direct laryngoscopy, videolaryngoscopy is associated with fewer failed intubations, improved glottic view and less trauma, but no consistent improvement in first-pass success, attempts, or respiratory complications.
Lewis SR, Butler AR, Parker J et al. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Db Syst Rev. 2016 Nov 15; 11 (11): CD011136CD011136.
  Daniel Jolley
pearl
1
For non-mastectomy breast surgery the PECS II block is no better than surgical local infiltration.
Barrington MJ, Seah GJ, Gotmaker R et al. Quality of Recovery After Breast Surgery: A Multicenter Randomized Clinical Trial Comparing Pectoral Nerves Interfascial Plane (Pectoral Nerves II) Block With Surgical Infiltration. Anesth. Analg. 2020 Jun 1; 130 (6): 1559-1567.
  Daniel Jolley
pearl
1
Using a flexible reinforced laryngeal mask is non-inferior to endotracheal intubation for thyroid surgery when considering only peak airway pressure and end-tidal CO_2.
Gong Y, Wang J, Xu X et al. Performance of Air Seal of Flexible Reinforced Laryngeal Mask Airway in Thyroid Surgery Compared With Endotracheal Tube: A Randomized Controlled Trial. Anesth. Analg. 2020 Jan 1; 130 (1): 217-223.
  Daniel Jolley
pearl
1
Current evidence is too limited to conclude any significant difference between phenylephrine and noradrenaline for managing CS hypotension due to spinal anaesthesia.
Heesen M, Hilber N, Rijs K et al. A systematic review of phenylephrine vs. noradrenaline for the management of hypotension associated with neuraxial anaesthesia in women undergoing caesarean section. Anaesthesia. 2020 Jun 1; 75 (6): 800-808.
  Daniel Jolley
summary
1
Fascinating introspection from an experienced psychiatrist on the ways the pandemic has subtly (and perhaps not-so-subtly) changed his interactions with patients and his perspective on his role as caregiver.
"...among the many unknown — and potentially positive — outcomes of the pandemic, one may be the more widespread realization that “acting like a doctor” ideally involves less acting and more authenticity."
Kahn MW. Pandemic and Persona. N. Engl. J. Med. 2020 Jul 2; 383 (1): e1.
  Daniel Jolley
pearl
1
Automated robotic intubation of the trachea is feasible.
Biro P, Hofmann P, Gage D et al. Automated tracheal intubation in an airway manikin using a robotic endoscope: a proof of concept study. Anaesthesia. 2020 Jul 1; 75 (7): 881-886.
  Daniel Jolley
pearl
1
Pre-operative anaemia is associated with increased mortality, prolonged hospital stay and return to theatre in patients having emergency laparotomy.
Boyd-Carson H, Shah A, Sugavanam A et al. The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia. 2020 Jul 1; 75 (7): 904-912.
  Daniel Jolley