Article Notes

• Hide
  • Pearls
  • Summaries
  • Comments

pearl
1
Obstructive sleep apnoea patients receiving opioids should have post-operative continuous monitoring.
Nagappa M, Subramani Y, Chung F. Best perioperative practice in management of ambulatory patients with obstructive sleep apnea. Curr Opin Anaesthesiol. 2018 Dec 1; 31 (6): 700-706.
  Daniel Jolley
pearl
1
Continuous femoral nerve block is better than single-shot femoral nerve block for providing analgesia after total knee replacement.
Chan EY, Fransen M, Parker DA et al. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Db Syst Rev. 2014 May 13; 2014 (5): CD009941CD009941.
  Daniel Jolley
pearl
1
Femoral nerve block is better than PCA alone after total knee replacement, although comparison to local infiltration is unclear.
Chan EY, Fransen M, Parker DA et al. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Db Syst Rev. 2014 May 13; 2014 (5): CD009941CD009941.
  Daniel Jolley
pearl
1
Even if beneficial, perioperative lignocaine infusions probably have no analgesic benefit beyond 24 hours post-operatively.
Weibel S, Jelting Y, Pace NL et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Db Syst Rev. 2018 Jun 4; 6: CD009642.
  Daniel Jolley
pearl
1
Optimizing depth of anesthesia with a processed EEG (BIS, Entropy, or similar) in surgical patients over 60 yo is probably beneficial by reducing the incidence of post-operative delirium and cognitive decline.
Punjasawadwong Y, Chau-In W, Laopaiboon M et al. Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults. Cochrane Db Syst Rev. 2018 May 15; 5 (5): CD011283CD011283.
  Daniel Jolley
pearl
1
Unlike dexmedetomidine sedation in the critical care setting, intraoperative dexmedetomidine does not reduce postoperative delirium.
Deiner S, Luo X, Lin HM et al. Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial. JAMA Surg. 2017 Aug 16; 152 (8): e171505.
  Daniel Jolley
pearl
1
Desflurane and propofol anesthesia are associated with similar incidence of post-operative delirium in the obese, elderly undergoing total knee replacement.
Tanaka P, Goodman S, Sommer BR et al. The effect of desflurane versus propofol anesthesia on postoperative delirium in elderly obese patients undergoing total knee replacement: A randomized, controlled, double-blinded clinical trial. J Clin Anesth. 2017 Jun 1; 39: 17-22.
  Daniel Jolley
pearl
1
Neuraxial morphine does not have a protective effect on headache after unintentional dural puncture.
Brinser ME, Seng DL, Mandell GL et al. Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients. J Clin Anesth. 2019 Feb 1; 52: 58-62.
  Daniel Jolley
summary
1
Why should you care?
Not only is venous cannulation a common procedure, but so is resultant thrombophlebitis – occurring in up to 75% of patients. This has important morbidity, patient-experience and economic consequences.
What does this study add?
Although many risk factors have been identified (insertion sterility, location, access technique, drug use, micro-particles, etc.), Villa and friends investigated whether in-line filters would reduce phlebitis incidence.
This modest, single-center trial randomized surgical patients between in-line filter (for 96 hours) or standard line, before anesthesia induction. Filter user reduced thrombophlebitis 13-fold at 48 hours, and at 96 hours sustained potency of 50% more of the cannulae.
What sort of filters did they use?
They used an 11 cm² positively-charged 0.2 µm filter for fluid and most drugs, a 4.5 cm² 1.2 µm filter for propofol infusions, and a positively-charged 1.65 cm² 0.2 µm for opioid infusions.
The filters did slow gravity-fed infusion rates as they aged, however this was not clinically significant when using a peristaltic pump.
The take-home...
We should be better stewards of our patient's IV access. For short-term access <48h focus should be on technique and sterility, but for access needed for 48h or longer, an inline filter offers significant benefit with limited downside.
Villa G, Chelazzi C, Giua R et al. In-Line Filtration Reduces Postoperative Venous Peripheral Phlebitis Associated With Cannulation: A Randomized Clinical Trial. Anesth. Analg. 2018 Dec 1; 127 (6): 1367-1374.
  Daniel Jolley
summary
1
Accurately identifying the cricothyroid membrane is foundational for front-of-neck rescue of airway misadventure. Yet the very patients who are at risk of a cannot intubate, cannot oxygenate scenario (eg. obese, neck pathology) are also likely to make identifying the cricothyroid membrane (CTM) difficult.
Naveed and co. compared the accuracy of CTM palpation to ultrasound in a single-blinded randomized trial of 223 patients, with poorly defined landmarks, undergoing CT neck.
The ultrasound group showed a 10-time greater success in identifying the CTM (correct within 5 mm of actual; 81% vs 8%), along with a 5-times smaller mean distance from actual to estimated, than did the palpation group.
So what's the take home?
Given the wide-availability of ultrasound and it's acceptability to patients, any pre-induction marking of the CTM in an anticipated difficult airway should employ neck ultrasound in all but the most obviously-palpable necks.
In an emergent CICO situation, neck ultrasound likely has utility, though at the potential cost of procedural complexity and delay.
Siddiqui N, Yu E, Boulis S et al. Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial. Anesthesiology. 2018 Dec 1; 129 (6): 1132-1139.
  Daniel Jolley