Article Notes
- Ensuring at least 30 min since last epidural bolus.
- Reducing spinal dose by 20%. (NB: plain bupivacaine used)
- Delay supine positioning for 2 min after spinal performed.
- Northern Territorians are "... three times more likely to die on the roads than people living in other parts of Australia, and at a rate that is equivalent to that in many low- and middle-income countries."
- After the last open speed limits were abolished in 2007, the "Australian road deaths database shows a decrease in fatalities of 3.4 per year on those NT roads..."
This controlled study randomised 212 children to either deep plane-of-anesthesia or awake, and either supine or lateral position, for removal of their laryngeal mask at the completion of surgery.
"Deep anesthesia" was defined as ET-sevoflurane 2.2%, stable for 1 minute. The "awake" group had their LMA removed by the PACU nurse after eye opening and/or obeying commands.
Airway complications included desaturation < 90%, stridor, laryngospasm, retching/vomiting, excess secretions and biting. A secondary outcome was also studied, assigning a 'clinical significance score' to the range of complications.
Deep removal in the lateral position was associated with the fewest complications. Deep removal when supine was associated with the most complications.
This study was a follow-up to a two-centre observational audit from 2008.
Daniel Jolley
Pieter Peach
An audit of 115 parturients requiring spinal anesthesia for cesarean section in the setting of an inadequate, pre-existing epidural block. Median dose of 9.38 mg of bupivacaine + 15 mcg fentanyl was used. No patients received an epidural bolus within 30 min of their subarachnoid block.
There were no cases of total spinal block.
Because total spinal after inadequate epidurals had been 'not uncommon' in the department, the researchers had altered the department's practice to be:
(Plus patient weight < 120 kg and height > 1.47 m)
Daniel Jolley
Far from earth-shattering, though what I find (possibly) interesting is the long delay between the last epidural dose and the (apparent) total spinal.
90 min seems like it should be well and truly long enough for any epidural bupivacaine to be absorbed – in fact, this is probably only a little shorter than the duration of said dose. It's possible that the total spinal was totally unrelated to the epidural, but that's probably wishful thinking.
Previous studies (Dadarkar, IJOA 2014) have suggested that waiting 30 min between last epidural dose and spinal is safe (audit of 115 patients in Dallas).
The take-away for me is that there's probably more patient variability than we'd like to admit.
Daniel Jolley
A case study describing a total spinal occurring in a 26 year old having an emergency caesarean section for failure to progress.
On arrival in theatre a block to pin prick was noted to T12, with the last epidural top-up having been 90 minutes earlier with only 5 mL of 0.25% bupivacaine. Total volume of epidural LA is not reported.
The epidural had partially dislodged, so anaesthesia was with 10.5 mg of spinal bupivacaine (equivalent to 2.1mL of 0.5%) resulting in a block to T6. 10 minutes later the patient became distressed, followed by respiratory arrest and unconsciousness.
Baby was delivered uneventfully and the mother made a full recovery. The authors ascribed the case to a total spinal resulting from cephalad spread of intrathecal bupivacaine.
Daniel Jolley
Allan Palmer
A clear and nuanced critique of the Northern Territory government's policy of removing speed limits on sections of the Stuart Highway. Read explores evidence linking driving speed and posted speed limits with vehicle accidents and trauma, noting that for the Territory:
He concludes that the NT needs a stronger road safety package that includes removing unlimited speed limits along with driver fatigue, alcohol and seatbelt interventions.
Daniel Jolley
This prospective observational study across eight Canadian hospitals identified post-operative residual paralysis in 64% of patients at extubation and 57% on arrival in the PACU, despite more than 70% of patients receiving reversal with neostigmine.
Rocuronium was the muscle relaxant used in 99% of cases.
Daniel Jolley
This retrospective propensity-matched cohort study, used 5 years of data to study 2,644 matched pairs-of-patients with a preoperative diagnosis of severe COPD.
Important exclusions were patients already ventilated, already with pulmonary infections, along with cardiac, emergency & transplant surgery, and those receiving repeat surgery within 30 days.
Receiving general anesthesia was associated with a 43% higher risk of respiratory infection (3.3% vs 2.3%, P = 0.0384), 133% greater risk of prolonged ventilation (2.1% vs 0.9%, P = 0.0008) and 44% greater risk of unplanned post-op intubation (2.6% vs 1.8%, P = 0.0487), when compared with regional anesthesia.
Nonetheless there was no significant mortality difference at 30 days (3.0% vs 2.7%, P = 0.6788).
The mix of regional techniques was 341 epidural, 1713 spinal, and 590 peripheral blocks. Notably, sub-group analysis of epidural-patients showed no difference in pulmonary complications or composite morbidity between epidural and general anesthesia. (Though given relatively small number of epidural patients, this might reflect a lack of power).
Daniel Jolley