We’re still doing too many unnecessary general anaesthetic cesarean sections. It is not enough to be confident that we can conduct a ‘safe’ GA CS (ie. misperceived as meaning a low mortality risk), when avoidable GA CS are still associated with a spectrum of morbidity.
Definitely falls into the category of ‘just because we can, doesn’t mean we should’...
Articulating positive expectations of analgesia efficacy preoperatively improves postoperative pain scores and analgesia satisfaction.
Checklists for managing crises during cesarean section are practical to implement in low and middle-income countries, and significantly improve task completion in simulated emergencies.
Although routine videolaryngoscopy does not improve overall success rate of adult nasal intubation, it does improve first pass success, laryngeal visualization and shortens intubation time.
Neuraxial anesthesia is associated with lower rates of perioperative transfusion in patients undergoing bilateral total hip replacement when compared to general anesthesia, although not significantly with other post-operative outcomes.
Dexmedetomidine may reduce post-operative delirium and at one month post-operative cognitive decline in elderly patients, associated with changes in brain-derived neurotrophic factor.
Children who are exposed to multiple general anaesthetics before age three demonstrate deficits on neurosphycological testing, although not children with a single exposure.
Although there is reasonable confidence that a single general anaesthetic before three years of age has no consequences for intelligence development, there is an association between multiple exposures and learning and behavioural difficulties, possibly including ADHD. Animal studies have demonstrated ADHD-like changes in juvenile rats exposed to general anaesthetics.
There is a plausible physiological explanation for how general anaesthesia may induce ADHD, involving disruption of the prefrontal cortex and basal ganglia via dopaminergic, glutaminergic and neutrophic factor mechanisms.
Nonetheless, evidence to date linking general anaesthetic exposure in young children and ADHD development is far from conclusive and – as with many areas of practice – requires further research.
The remifentanil PCA for labour analgesia controversy continues...
Those advocating its first-line use point to reassuring evidence of maternal satisfaction and acceptability, reduced epidural rates, and some suggestion of reduced instrumental delivery rates.
For the negative, the ongoing safety concerns created by routine use of remifentanil PCAs are foremost, particularly given how uneven hospitals can be at implementing best safety practices. Observed rates of significant desaturation range from 25-70%, in addition to potential neonatal effects.
The greatest challenge facing the remiPCA advocates, is that the labour epidural is still the most effective form of labour analgesia, and has only improved over the decades as safety has been both maintained and increased.
Maternal desaturation is common during remifentanil PCA analgesia for labour.