Why is this important?
6% of the world's population has diabetes mellitus, making it one of the most common perioperative comorbidities. Withholding oral-hypoglycaemics pre-op is common, but worsens glucose control and so may increase post-op complications.
What did they find?
Ambulatory patients who had their metformin and/or sulphonylurea OHG agents continued perioperatively had better glucose control.
Be cautious as this was a relatively small study, and not adequately powered to compare hypoglycaemia rates or (ridiculously) rare complications such as lactic acidosis. Additionally, no investigation was made of post-op complications, instead using glucose control as a surrogate outcome.
It's probably safe and beneficial to continue metformin and sulphonylureas perioperatively in those having ambulatory day-surgery with normal renal function.
In children single-agent antiemetic prophylaxis is as equally effective as TIVA in preventing post-operative vomiting.
Important caveats to temper our sugammadex enthuasiasm...
- Sugammadex is still cost-prohibitive for many health systems.
- Although neuromuscular reversal is demonstrably better than for neostigmine, sugammadex use does not obviate the need for neuromuscular monitoring (Kotake 2013: Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block).
- Sugammadex is an important option to consider in a CICO crisis, but it is not a ‘Get Out of Gaol Free’ card (Kyle 2012: A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex).
- Sugammadex is now the leading cause of perioperative anaphylaxis in Japan, and we have likely underestimated the risk of sugammadex hypersensitivity. (see: Sugammadex anaphylaxis: all that glitters?).
Is the conventional assumption that left-lateral tilt and uterine displacement avoids aortocaval compression during Caesarean section actually valid?
50 years of assumed orthodoxy is challenged by studies showing that:
- True aortal compression is relatively uncommon (Higuchi 2015, Lee 2012).
- Caval compression is probably near-universal, but also usually not improved by a mere 15 degree tilt. (An impractical 30 degrees is more likely required for meaningful impact!) (Palmer 2015).
- Caval compression probably has limited haemodynamic or fetal consequences in the fit, well, term parturient (Higuchi 2015; Lee 2012).
- Judicious use of vasopressor infusions may obviate the need for traditional uterine displacement (Lee 2017; Farber 2017).
Time to change practice then?
Not quite yet...
Duration of rocuronium action directly correlates with BMI.
Intraoperative dexamethasone reduces the incidence of postoperative sore throat for up to 24 hours and postoperative hoarseness for 1 hour.
Use of smaller-sized ETT results in less post-operative sore throat in female patients.
Women experience less frequent and less severe sore throat postoperatively after intubation with a size 6.0 ETT versus size 7.0.
Optimal intraoperative PEEP varies among patients. Individualizing PEEP reduces post-operative atelectasis.
Case report from Yamaguchi, Japan describing a confirmed sugammadex anaphylaxis in a 50kg woman receiving 4mg/kg sugammadex.
Notably, follow-up skin prick testing strongly suggests #1 hypersensitivity to free sugammadex molecules, rather than the sugammadex-rocuronium complex, and #2 hypersensitivity appears to be dose-related.