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Interesting editorial accompanying Dr Peter Schuller's excellent study of BIS values in awake, paralysed volunteers.
The editors make a very interesting point critiquing the probabilistic, database-based approach to processed-EEG awareness monitors like BIS: (emphasis added)
"This database-driven approach may have limitations, in particular for the detection of intraoperative wakefulness: it is very unlikely that data from an awake and paralyzed subject are included in this database. Therefore, the resulting anaesthesia index has not been trained with a dataset that contains this clinical situation..."
Schneider G Pilge S. Restrict relaxants, be aware, and know the limitations of your depth of anaesthesia monitor. Br J Anaesth. 2015 Jul 1;115 Suppl 1:i11-i12.
  Daniel Jolley
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Awareness occurred in 1 in 19,000 general anaesthetics, resulting in distress in 51% of cases and longterm harm in 41%. BIS monitoring was used in 5% of cases of awareness.
Cook TM, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues†‡ Br J Anaesth. 2014 Oct 1;113(4):560-74.
  Daniel Jolley
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Wow! They had a 21% incidence of PDPH in their control group (and almost 8% in the treatment arm) because they were using 25g Quincke needles! It is interesting that they have access to ondansetron but presumably not pencil-point needles.
This study leaves me asking why? why? why?
Fattahi Z, Hadavi SM, Sahmeddini MA. Effect of ondansetron on post-dural puncture headache (PDPH) in parturients undergoing cesarean section: a double-blind randomized placebo-controlled study. J Anesth. 2015 Oct 1; 29 (5): 702-7.
  Daniel Jolley
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Fascinating. Hazard of small studies but would love to see a mechanism. Big dose of Ondansetron too. Ummm.
Fattahi Z, Hadavi SM, Sahmeddini MA. Effect of ondansetron on post-dural puncture headache (PDPH) in parturients undergoing cesarean section: a double-blind randomized placebo-controlled study. J Anesth. 2015 Oct 1; 29 (5): 702-7.
  Allan Palmer
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0
Though has limited application outside of the low-resource setting. This basically shows ketofol is non-inferior to propofol alone, rather than superior.
The audited group is a pretty low-risk one for negative hemodynamic consequences from propofol (alone) sedation. Adding a drug (ketamine) increases technique complexity and needs to be balanced against a demonstrable benefit.
Grace RF, Tang DW, Namel E. An audit of the haemodynamic and emergence characteristics of single-shot 'ketofol'. Anaesth Intensive Care. 2015 Jul 1; 43 (4): 503-5.
  Daniel Jolley
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A small audit showing the acceptability and absence of significant side effects of ketofol when used for brief procedural sedation (tubal ligation), particularly in the low resource setting.
Patients received a premixed ketofol dose of 0.5 mg/kg ketamine and 0.9 mg/kg propofol after fentanyl 1 mcg/kg.
Notably there was universal hemodynamic stability, although almost half of the audited patients required airway support.
Grace RF, Tang DW, Namel E. An audit of the haemodynamic and emergence characteristics of single-shot 'ketofol'. Anaesth Intensive Care. 2015 Jul 1; 43 (4): 503-5.
  Daniel Jolley
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1
Implementation of the Surgical Safety Checklist in Ontario, Canada did not reduce surgical morbidity or mortality.
Urbach DR, Govindarajan A, Saskin R et al. Introduction of surgical safety checklists in Ontario, Canada. N. Engl. J. Med. 2014 Mar 13;370(11):1029-38.
  Daniel Jolley
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Collection: Surgical safety checklists
The World Health Organisation's Surgical Safety Checklist has been adopted and implemented by many hospitals throughout the world: from large tertiary teaching hospitals in wealthy countries, to small hospitals in low-resource settings.
The benefits to each hospital however are likely not the same. Does the WHO SSC implemented in a hospital that already has a 'Time Out' process bring the same benefit, if any, as to a hospital for which the checklist was completely new? Possibly not.
Several studies across a wide range of health systems have shown conflicting results in terms of reducing morbidity, mortality and length of stay.
  Daniel Jolley
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Good critique of this study by Skeptical Scalpel here:
Do OR checklists improve outcomes?
Haugen AS, Søfteland E, Almeland SK et al. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann. Surg. 2015 May 1;261(5):821-8.
  Daniel Jolley
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It's fascinating that the mechanism of something as common as propofol-injection pain is still not completely understood.
Galgon RE, Strube P, Heier J et al. Magnesium sulfate with lidocaine for preventing propofol injection pain: a randomized, double-blind, placebo-controlled trial. J Anesth. 2015 Apr 1;29(2):206-11.
  Daniel Jolley