Article Notes
I like that POISE is another example in anaesthesia and peri-operative medicine of where surgery and anaesthesia themselves are not sufficient indications for intervening in a way (ie. starting peri-operative beta-blockers) that is not otherwise medically indicated (ie. as Allan notes, 'requiring beta blockade for cardiac reasons'). Screening coronary angiograms and revascularisation before major surgery are other examples.
There is a bit of "when will we learn?" to the beta-blockade story.
It is important to note that the drivers of growth in Office Based Anesthesia are primarily economic and professional autonomy focused rather than patient care or quality of care. That is not to say these former priorities are in opposition to patient-centered goals, just that the patient is not the primary diver of this shift.
Of course the issue here is whether occlusion of the oesophageal entrance sufficient to prevent antegrade passage of a flexible silicon tube is a valid surrogate for the ability to prevent retrograde passage of liquid (ie. gastric fluid). There is a significant difference here and I feel this research adds little to the debate regarding benefit (or not) of cricoid pressure.
Interesting to note that not only did the pudendal nerve block group experience better analgesia than the caudal block group, they were also exposed to a much smaller absolute dose of bupivacaine (0.75 mg/kg vs 2.5 mg/kg). This is important not only because of the safety implications, but also because allows extra LA for top-up if the block is inadequate or fails.
Although this Cochrane review supports the belief that epidural and paravertebral blocks may reduce persistent-surgical pain after thoracotomy or breast cancer surgery respectively, the authors highlight the low total number of subjects (only 339 patients) in the five trials analysed. This is enough evidence to consider the PSP-benefits of regional anesthesia, but far from enough to be conclusive or change practice.
Note that this was firstly a retrospective trial, and secondly that it was a re-analysis of data from an earlier study, the 'Vitamins In Nitrous Oxide trial', and as such not designed with assessment of this article's end point in mind.
Nonetheless an interesting and relevant finding that calls in to question the idea that intra-operative N2O has post-operative analgesia benefit via it's known NMDA antagonism. As with many things, *further studies are required"...